Joyce Frieden

WASHINGTON — Technology has driven down the cost of genetic research, allowing for greater progress in finding gene targets associated with chronic diseases, including diabetes, according to Dr. Francis S. Collins, director of the National Human Genome Research Institute.

To search across the entire human genome for genes involved in a particular disease would have cost about $10 billion 5 years ago; thanks to the Human Genome Project, the same work now can be done for $500,000, said Dr. Collins at a diabetes meeting sponsored by Avalere Health.

Currently, there are more than a dozen genetic variants thought to predispose people to type 1 diabetes, “many of which were previously not suspected,” said Dr. Collins.

Three genes—TCF7L2, KCNJ11, and PPAR gamma—have previously been identified as having variants associated with type 2 diabetes risk. Now, with advances in methods for detecting gene variants, the list has grown to 10, with “5 more in press from additional studies,” he said.

One interesting new variant is SLC30A8, “which I never heard of or thought about until it popped out of [an] analysis,” said Dr. Collins. SLC30A8 codes for a protein that is expressed only in b cells.

“What it does is serve as a zinc transporter; it apparently is the pump that moves the zinc into the granules where it complexes with insulin getting ready for secretion,” he said. “Insulin is complexed with zinc in a crystal, and if you don't have the right amount of zinc, that's probably not going to help your ability to secrete insulin when you need to.”

A variation like that might serve as a worthy target for therapeutic intervention, according to Dr. Collins.

“There is some interesting data in animal models [showing] that zinc itself may actually be effective in preventing diabetes,” he said, adding that there is very little human data in this area. “We might discover that it could be useful for people who have this particular zinc transporter [variant] that causes it not to work as well as we'd like—maybe simply by zinc supplementation, we could accommodate that. We don't know that; that's speculation, but we're thinking about ways to test that hypothesis.”

Discoveries of particular variants related to diabetes also might help more people than just those who have the variant, Dr. Collins said. For example, one already-discovered variant, KCNJ11, “codes for the protein that is the product of a sulfonylurea class of drugs. And what is PPAR gamma? That is the gene that codes for the protein that is the target of thiazolidinediones. So here you have proof that this strategy is capable of identifying drug targets, and we know those drugs work [on people other than] those who have one spelling or the other of these particular genes.”

In terms of the increased risk posed by the gene variants, “most of these are pretty modest”—for instance, if you have the variant of PCF7L2, your likelihood of getting diabetes would go up 37%, he explained. “But of course that doesn't mean you're definitely going to get the disease.”

However, some people have argued that this information could be used to predict whether certain healthy individuals are likely to get diabetes, “and in fact, if you have a fair number of these risk factors, you can already use this to predict that some people have about twice the average baseline risk of diabetes and others may have as little as half that baseline risk, and that's starting to get into the zone where that might be useful information,” Dr. Collins said.

Another area where genetic information could be useful is in predicting which diabetes patients will wind up with particular complications. “It may also be that some of these [variants] predispose some people to complications more than others, and we need to know that information as soon as we can,” Dr. Collins said. “We have a study going on right now with diabetic nephropathy, with results expected later this year.”

Genetic information could be useful in predicting which patients will suffer from particular complications. DR. COLLINS

WASHINGTON — Technology has driven down the cost of genetic research, allowing for greater progress in finding gene targets associated with chronic diseases, including diabetes, according to Dr. Francis S. Collins, director of the National Human Genome Research Institute.

To search across the entire human genome for genes involved in a particular disease would have cost about $10 billion 5 years ago; thanks to the Human Genome Project, the same work now can be done for $500,000, said Dr. Collins at a diabetes meeting sponsored by Avalere Health.

Currently, there are more than a dozen genetic variants thought to predispose people to type 1 diabetes, “many of which were previously not suspected,” said Dr. Collins.

Three genes—TCF7L2, KCNJ11, and PPAR gamma—have previously been identified as having variants associated with type 2 diabetes risk. Now, with advances in methods for detecting gene variants, the list has grown to 10, with “5 more in press from additional studies,” he said.

One interesting new variant is SLC30A8, “which I never heard of or thought about until it popped out of [an] analysis,” said Dr. Collins. SLC30A8 codes for a protein that is expressed only in b cells.

“What it does is serve as a zinc transporter; it apparently is the pump that moves the zinc into the granules where it complexes with insulin getting ready for secretion,” he said. “Insulin is complexed with zinc in a crystal, and if you don't have the right amount of zinc, that's probably not going to help your ability to secrete insulin when you need to.”

A variation like that might serve as a worthy target for therapeutic intervention, according to Dr. Collins.

“There is some interesting data in animal models [showing] that zinc itself may actually be effective in preventing diabetes,” he said, adding that there is very little human data in this area. “We might discover that it could be useful for people who have this particular zinc transporter [variant] that causes it not to work as well as we'd like—maybe simply by zinc supplementation, we could accommodate that. We don't know that; that's speculation, but we're thinking about ways to test that hypothesis.”

Discoveries of particular variants related to diabetes also might help more people than just those who have the variant, Dr. Collins said. For example, one already-discovered variant, KCNJ11, “codes for the protein that is the product of a sulfonylurea class of drugs. And what is PPAR gamma? That is the gene that codes for the protein that is the target of thiazolidinediones. So here you have proof that this strategy is capable of identifying drug targets, and we know those drugs work [on people other than] those who have one spelling or the other of these particular genes.”

In terms of the increased risk posed by the gene variants, “most of these are pretty modest”—for instance, if you have the variant of PCF7L2, your likelihood of getting diabetes would go up 37%, he explained. “But of course that doesn't mean you're definitely going to get the disease.”

However, some people have argued that this information could be used to predict whether certain healthy individuals are likely to get diabetes, “and in fact, if you have a fair number of these risk factors, you can already use this to predict that some people have about twice the average baseline risk of diabetes and others may have as little as half that baseline risk, and that's starting to get into the zone where that might be useful information,” Dr. Collins said.

Another area where genetic information could be useful is in predicting which diabetes patients will wind up with particular complications. “It may also be that some of these [variants] predispose some people to complications more than others, and we need to know that information as soon as we can,” Dr. Collins said. “We have a study going on right now with diabetic nephropathy, with results expected later this year.”

Genetic information could be useful in predicting which patients will suffer from particular complications. DR. COLLINS

WASHINGTON — Technology has driven down the cost of genetic research, allowing for greater progress in finding gene targets associated with chronic diseases, including diabetes, according to Dr. Francis S. Collins, director of the National Human Genome Research Institute.

To search across the entire human genome for genes involved in a particular disease would have cost about $10 billion 5 years ago; thanks to the Human Genome Project, the same work now can be done for $500,000, said Dr. Collins at a diabetes meeting sponsored by Avalere Health.

Currently, there are more than a dozen genetic variants thought to predispose people to type 1 diabetes, “many of which were previously not suspected,” said Dr. Collins.

Three genes—TCF7L2, KCNJ11, and PPAR gamma—have previously been identified as having variants associated with type 2 diabetes risk. Now, with advances in methods for detecting gene variants, the list has grown to 10, with “5 more in press from additional studies,” he said.

One interesting new variant is SLC30A8, “which I never heard of or thought about until it popped out of [an] analysis,” said Dr. Collins. SLC30A8 codes for a protein that is expressed only in b cells.

“What it does is serve as a zinc transporter; it apparently is the pump that moves the zinc into the granules where it complexes with insulin getting ready for secretion,” he said. “Insulin is complexed with zinc in a crystal, and if you don't have the right amount of zinc, that's probably not going to help your ability to secrete insulin when you need to.”

A variation like that might serve as a worthy target for therapeutic intervention, according to Dr. Collins.

“There is some interesting data in animal models [showing] that zinc itself may actually be effective in preventing diabetes,” he said, adding that there is very little human data in this area. “We might discover that it could be useful for people who have this particular zinc transporter [variant] that causes it not to work as well as we'd like—maybe simply by zinc supplementation, we could accommodate that. We don't know that; that's speculation, but we're thinking about ways to test that hypothesis.”

Discoveries of particular variants related to diabetes also might help more people than just those who have the variant, Dr. Collins said. For example, one already-discovered variant, KCNJ11, “codes for the protein that is the product of a sulfonylurea class of drugs. And what is PPAR gamma? That is the gene that codes for the protein that is the target of thiazolidinediones. So here you have proof that this strategy is capable of identifying drug targets, and we know those drugs work [on people other than] those who have one spelling or the other of these particular genes.”

In terms of the increased risk posed by the gene variants, “most of these are pretty modest”—for instance, if you have the variant of PCF7L2, your likelihood of getting diabetes would go up 37%, he explained. “But of course that doesn't mean you're definitely going to get the disease.”

However, some people have argued that this information could be used to predict whether certain healthy individuals are likely to get diabetes, “and in fact, if you have a fair number of these risk factors, you can already use this to predict that some people have about twice the average baseline risk of diabetes and others may have as little as half that baseline risk, and that's starting to get into the zone where that might be useful information,” Dr. Collins said.

Another area where genetic information could be useful is in predicting which diabetes patients will wind up with particular complications. “It may also be that some of these [variants] predispose some people to complications more than others, and we need to know that information as soon as we can,” Dr. Collins said. “We have a study going on right now with diabetic nephropathy, with results expected later this year.”

Genetic information could be useful in predicting which patients will suffer from particular complications. DR. COLLINS

Endocrinologists are urging members of Congress to stop a potential Medicare payment cut for dual-energy x-ray absorptiometry exams.

Members of the American Association of Clinical Endocrinologists (AACE) are “very concerned” about the pending cut, said Dr. Jonathan Leffert, chairman of AACE's legislative and regulatory committee. “We think it will cause significant access problems for people who have osteoporosis.”

The current Medicare payment rate for a DXA scan is about $80, Dr. Leffert said, noting that a survey from the Lewin Group put break-even reimbursement for a DXA scan at $139. “If the cuts are continued [as planned], by 2010, Medicare will pay $50 for DXA,” he said. “At $80 we're losing money, and at $50, it's untenable.”

Dr. Leffert said he already had heard from one New York physician who sold the two DXA machines he had in his office because he was losing too much money on the procedure. And Dr. Leffert said he recently had a patient who lived in a rural area try to get a DXA scan from a mobile unit that she had used in years past, only to find that it had gone out of business.

A DXA scan is one of the items included in the “Welcome to Medicare” physical exam, but many endocrinologists can't afford to provide the test because of the low reimbursement, Dr. Leffert said. He added that Medicare also does not allow physicians to bill the balance to patients to make up the difference between what they charge and what Medicare will pay.

The low DXA reimbursement “will have a significant effect in the long term because of [increased] fractures and the morbidity and mortality associated with that,” said Dr. Leffert, who is also in private practice in Dallas. “About 20%–25% of people who have hip fractures, for example, will die within a year due to related complications.”

The 18 AACE members who participated in the association's annual Capitol Hill lobbying event were seeking support for H.R. 4206, the Medicare Fracture Prevention and Osteoporosis Testing Act of 2007. The bill, sponsored by Rep. Shelley Berkley (D-Nev.), would establish a national minimum payment amount for DXA as well as for vertebral fracture assessment, and would set the minimum payment amount at no less than 100% of the reimbursement rates in effect for those codes at the end of 2006 (about $140 in the case of DXA). It also would require the Institute of Medicine to report on the effects of DXA reimbursement cuts.

So far, the bill has 55 cosponsors, Dr. Leffert noted, adding that a Senate companion bill is in the works. The AACE delegation also sought support for H.R. 1293, sponsored by Rep. Carolyn McCarthy (D-N.Y.). That bill would put a 2-year moratorium on payment cuts for certain advanced diagnostic imaging procedures.

Endocrinologists are urging members of Congress to stop a potential Medicare payment cut for dual-energy x-ray absorptiometry exams.

Members of the American Association of Clinical Endocrinologists (AACE) are “very concerned” about the pending cut, said Dr. Jonathan Leffert, chairman of AACE's legislative and regulatory committee. “We think it will cause significant access problems for people who have osteoporosis.”

The current Medicare payment rate for a DXA scan is about $80, Dr. Leffert said, noting that a survey from the Lewin Group put break-even reimbursement for a DXA scan at $139. “If the cuts are continued [as planned], by 2010, Medicare will pay $50 for DXA,” he said. “At $80 we're losing money, and at $50, it's untenable.”

Dr. Leffert said he already had heard from one New York physician who sold the two DXA machines he had in his office because he was losing too much money on the procedure. And Dr. Leffert said he recently had a patient who lived in a rural area try to get a DXA scan from a mobile unit that she had used in years past, only to find that it had gone out of business.

A DXA scan is one of the items included in the “Welcome to Medicare” physical exam, but many endocrinologists can't afford to provide the test because of the low reimbursement, Dr. Leffert said. He added that Medicare also does not allow physicians to bill the balance to patients to make up the difference between what they charge and what Medicare will pay.

The low DXA reimbursement “will have a significant effect in the long term because of [increased] fractures and the morbidity and mortality associated with that,” said Dr. Leffert, who is also in private practice in Dallas. “About 20%–25% of people who have hip fractures, for example, will die within a year due to related complications.”

The 18 AACE members who participated in the association's annual Capitol Hill lobbying event were seeking support for H.R. 4206, the Medicare Fracture Prevention and Osteoporosis Testing Act of 2007. The bill, sponsored by Rep. Shelley Berkley (D-Nev.), would establish a national minimum payment amount for DXA as well as for vertebral fracture assessment, and would set the minimum payment amount at no less than 100% of the reimbursement rates in effect for those codes at the end of 2006 (about $140 in the case of DXA). It also would require the Institute of Medicine to report on the effects of DXA reimbursement cuts.

So far, the bill has 55 cosponsors, Dr. Leffert noted, adding that a Senate companion bill is in the works. The AACE delegation also sought support for H.R. 1293, sponsored by Rep. Carolyn McCarthy (D-N.Y.). That bill would put a 2-year moratorium on payment cuts for certain advanced diagnostic imaging procedures.

Endocrinologists are urging members of Congress to stop a potential Medicare payment cut for dual-energy x-ray absorptiometry exams.

Members of the American Association of Clinical Endocrinologists (AACE) are “very concerned” about the pending cut, said Dr. Jonathan Leffert, chairman of AACE's legislative and regulatory committee. “We think it will cause significant access problems for people who have osteoporosis.”

The current Medicare payment rate for a DXA scan is about $80, Dr. Leffert said, noting that a survey from the Lewin Group put break-even reimbursement for a DXA scan at $139. “If the cuts are continued [as planned], by 2010, Medicare will pay $50 for DXA,” he said. “At $80 we're losing money, and at $50, it's untenable.”

Dr. Leffert said he already had heard from one New York physician who sold the two DXA machines he had in his office because he was losing too much money on the procedure. And Dr. Leffert said he recently had a patient who lived in a rural area try to get a DXA scan from a mobile unit that she had used in years past, only to find that it had gone out of business.

A DXA scan is one of the items included in the “Welcome to Medicare” physical exam, but many endocrinologists can't afford to provide the test because of the low reimbursement, Dr. Leffert said. He added that Medicare also does not allow physicians to bill the balance to patients to make up the difference between what they charge and what Medicare will pay.

The low DXA reimbursement “will have a significant effect in the long term because of [increased] fractures and the morbidity and mortality associated with that,” said Dr. Leffert, who is also in private practice in Dallas. “About 20%–25% of people who have hip fractures, for example, will die within a year due to related complications.”

The 18 AACE members who participated in the association's annual Capitol Hill lobbying event were seeking support for H.R. 4206, the Medicare Fracture Prevention and Osteoporosis Testing Act of 2007. The bill, sponsored by Rep. Shelley Berkley (D-Nev.), would establish a national minimum payment amount for DXA as well as for vertebral fracture assessment, and would set the minimum payment amount at no less than 100% of the reimbursement rates in effect for those codes at the end of 2006 (about $140 in the case of DXA). It also would require the Institute of Medicine to report on the effects of DXA reimbursement cuts.

So far, the bill has 55 cosponsors, Dr. Leffert noted, adding that a Senate companion bill is in the works. The AACE delegation also sought support for H.R. 1293, sponsored by Rep. Carolyn McCarthy (D-N.Y.). That bill would put a 2-year moratorium on payment cuts for certain advanced diagnostic imaging procedures.

Fla. Ruling Affects Levothyroxine Rx

A ruling by a Florida administrative law judge means pharmacists in that state now are free to substitute generic levothyroxine sodium for brand-name formulations of the drug. The January decision that removed Synthroid, Levoxyl, Levothroid, and Unithroid from the negative formulary list came in response to a petition last August by Mylan Inc., which markets a generic form of levothyroxine. Prescriptions for drugs on a negative formulary list may not be substituted. Judge Susan B. Harrell noted in her decision that Abbott argued that removing levothyroxine from the negative drug formulary would endanger patients because pharmacists could substitute a generic drug which is not therapeutically equivalent to the prescribed brand-name drug. However, that issue is already covered by existing laws on generic substitution, she added. “The legislature has left it to the professional judgment of licensed pharmacists to determine what substitutions would not pose a threat to the health and safety of the patients,” Judge Harrell wrote. In an alert to its Florida members, the American Association of Clinical Endocrinologists noted that as a result of the ruling, “the only way to ensure your prescription or refill order is honored to your specifications is to write 'Medically Necessary' on the prescription.” Abbott Laboratories, which makes Synthroid, has filed an appeal.

Baseball Drug Exemptions Skyrocket

The number of “therapeutic use exemptions” given to Major League Baseball players tripled between 2006 and 2007, according to statistics recently released by the House Oversight and Government Reform Committee. In 2007, MLB granted 111 exemptions, compared with 35 in 2006. Of the 111 exemptions granted last year, 103 were for medications to treat attention-deficit/hyperactivity disorder; 5 were for treating hypertension, 1 was for treating alopecia areata, and 2 were for treating androgen deficiency. Of the 35 granted in 2006, 28 were for ADHD, 4 were for hypertension, and 3 were for androgen deficiency. The ADHD exemptions in 2007 “would appear to be an exceptionally high percentage, somewhat over … eight times the percentage of regular adults taking [ADHD] medication in our population,” John Tierney (D-Mass.), committee member, said at a hearing on steroid use in Major League Baseball. MLB Commissioner Bud Selig said the exemptions were “within the limit of the adult population. … We are reviewing that right now, trying to break down exactly why it happened and how it happened.”

Pay for Remote Monitoring

Reimbursement for remote monitoring may be added to a Medicare physician fee fix bill when it is taken up later this year, officials from AdvaMed, a lobbying group for medical device companies, said at a briefing last month. AdvaMed has met with staff from the Centers for Medicare and Medicaid Services to discuss coding for remote management of conditions such as heart failure, cardiac arrhythmia, diabetes, sleep apnea, and epilepsy. The coding discussions may provide the necessary momentum, said Stephen J. Ubl, AdvaMed president and CEO. The device lobby estimates that remote monitoring would cost $100 million or less over a 5-year period. Mr. Ubl also expressed hope that the Medicare package will include funds for a demonstration project to test a new payment system for certain molecular diagnostics. That would fix a flawed system, which pays less for new tests that may offer greater value to patients, he said. The pilot proposal is in S. 2404, which is sponsored by Sen. Chuck Schumer (D-N.Y.).

ACC on Vytorin Queries

The American College of Cardiology said it is cooperating with the House Energy and Commerce Committee on its requests to furnish information on funds the college has received from Merck & Co./Schering-Plough Corp., the joint venture that makes and sells Vytorin (ezetimibe/simvastatin). The drug combination has been the subject of intense scrutiny by the committee, largely because of delays in releasing data from the ENHANCE study. The committee said it wanted to know the nature of financial contributions made by the drug companies because the ACC and the American Heart Association had issued statements urging patients not to stop taking Vytorin without talking to their physicians first. The committee also requested data from the American Heart Association. Rep. Bart Stupak (D-Mich.), chairman of the oversight and investigations subcommittee, said his panel would look at “how they use this funding and any potential conflicts of interest.” An ACC spokesperson said the organization had delivered boxes of material to the committee, adding, “industry support in no way affects our policies.”

Fla. Ruling Affects Levothyroxine Rx

A ruling by a Florida administrative law judge means pharmacists in that state now are free to substitute generic levothyroxine sodium for brand-name formulations of the drug. The January decision that removed Synthroid, Levoxyl, Levothroid, and Unithroid from the negative formulary list came in response to a petition last August by Mylan Inc., which markets a generic form of levothyroxine. Prescriptions for drugs on a negative formulary list may not be substituted. Judge Susan B. Harrell noted in her decision that Abbott argued that removing levothyroxine from the negative drug formulary would endanger patients because pharmacists could substitute a generic drug which is not therapeutically equivalent to the prescribed brand-name drug. However, that issue is already covered by existing laws on generic substitution, she added. “The legislature has left it to the professional judgment of licensed pharmacists to determine what substitutions would not pose a threat to the health and safety of the patients,” Judge Harrell wrote. In an alert to its Florida members, the American Association of Clinical Endocrinologists noted that as a result of the ruling, “the only way to ensure your prescription or refill order is honored to your specifications is to write 'Medically Necessary' on the prescription.” Abbott Laboratories, which makes Synthroid, has filed an appeal.

Baseball Drug Exemptions Skyrocket

The number of “therapeutic use exemptions” given to Major League Baseball players tripled between 2006 and 2007, according to statistics recently released by the House Oversight and Government Reform Committee. In 2007, MLB granted 111 exemptions, compared with 35 in 2006. Of the 111 exemptions granted last year, 103 were for medications to treat attention-deficit/hyperactivity disorder; 5 were for treating hypertension, 1 was for treating alopecia areata, and 2 were for treating androgen deficiency. Of the 35 granted in 2006, 28 were for ADHD, 4 were for hypertension, and 3 were for androgen deficiency. The ADHD exemptions in 2007 “would appear to be an exceptionally high percentage, somewhat over … eight times the percentage of regular adults taking [ADHD] medication in our population,” John Tierney (D-Mass.), committee member, said at a hearing on steroid use in Major League Baseball. MLB Commissioner Bud Selig said the exemptions were “within the limit of the adult population. … We are reviewing that right now, trying to break down exactly why it happened and how it happened.”

Pay for Remote Monitoring

Reimbursement for remote monitoring may be added to a Medicare physician fee fix bill when it is taken up later this year, officials from AdvaMed, a lobbying group for medical device companies, said at a briefing last month. AdvaMed has met with staff from the Centers for Medicare and Medicaid Services to discuss coding for remote management of conditions such as heart failure, cardiac arrhythmia, diabetes, sleep apnea, and epilepsy. The coding discussions may provide the necessary momentum, said Stephen J. Ubl, AdvaMed president and CEO. The device lobby estimates that remote monitoring would cost $100 million or less over a 5-year period. Mr. Ubl also expressed hope that the Medicare package will include funds for a demonstration project to test a new payment system for certain molecular diagnostics. That would fix a flawed system, which pays less for new tests that may offer greater value to patients, he said. The pilot proposal is in S. 2404, which is sponsored by Sen. Chuck Schumer (D-N.Y.).

ACC on Vytorin Queries

The American College of Cardiology said it is cooperating with the House Energy and Commerce Committee on its requests to furnish information on funds the college has received from Merck & Co./Schering-Plough Corp., the joint venture that makes and sells Vytorin (ezetimibe/simvastatin). The drug combination has been the subject of intense scrutiny by the committee, largely because of delays in releasing data from the ENHANCE study. The committee said it wanted to know the nature of financial contributions made by the drug companies because the ACC and the American Heart Association had issued statements urging patients not to stop taking Vytorin without talking to their physicians first. The committee also requested data from the American Heart Association. Rep. Bart Stupak (D-Mich.), chairman of the oversight and investigations subcommittee, said his panel would look at “how they use this funding and any potential conflicts of interest.” An ACC spokesperson said the organization had delivered boxes of material to the committee, adding, “industry support in no way affects our policies.”

Fla. Ruling Affects Levothyroxine Rx

A ruling by a Florida administrative law judge means pharmacists in that state now are free to substitute generic levothyroxine sodium for brand-name formulations of the drug. The January decision that removed Synthroid, Levoxyl, Levothroid, and Unithroid from the negative formulary list came in response to a petition last August by Mylan Inc., which markets a generic form of levothyroxine. Prescriptions for drugs on a negative formulary list may not be substituted. Judge Susan B. Harrell noted in her decision that Abbott argued that removing levothyroxine from the negative drug formulary would endanger patients because pharmacists could substitute a generic drug which is not therapeutically equivalent to the prescribed brand-name drug. However, that issue is already covered by existing laws on generic substitution, she added. “The legislature has left it to the professional judgment of licensed pharmacists to determine what substitutions would not pose a threat to the health and safety of the patients,” Judge Harrell wrote. In an alert to its Florida members, the American Association of Clinical Endocrinologists noted that as a result of the ruling, “the only way to ensure your prescription or refill order is honored to your specifications is to write 'Medically Necessary' on the prescription.” Abbott Laboratories, which makes Synthroid, has filed an appeal.

Baseball Drug Exemptions Skyrocket

The number of “therapeutic use exemptions” given to Major League Baseball players tripled between 2006 and 2007, according to statistics recently released by the House Oversight and Government Reform Committee. In 2007, MLB granted 111 exemptions, compared with 35 in 2006. Of the 111 exemptions granted last year, 103 were for medications to treat attention-deficit/hyperactivity disorder; 5 were for treating hypertension, 1 was for treating alopecia areata, and 2 were for treating androgen deficiency. Of the 35 granted in 2006, 28 were for ADHD, 4 were for hypertension, and 3 were for androgen deficiency. The ADHD exemptions in 2007 “would appear to be an exceptionally high percentage, somewhat over … eight times the percentage of regular adults taking [ADHD] medication in our population,” John Tierney (D-Mass.), committee member, said at a hearing on steroid use in Major League Baseball. MLB Commissioner Bud Selig said the exemptions were “within the limit of the adult population. … We are reviewing that right now, trying to break down exactly why it happened and how it happened.”

Pay for Remote Monitoring

Reimbursement for remote monitoring may be added to a Medicare physician fee fix bill when it is taken up later this year, officials from AdvaMed, a lobbying group for medical device companies, said at a briefing last month. AdvaMed has met with staff from the Centers for Medicare and Medicaid Services to discuss coding for remote management of conditions such as heart failure, cardiac arrhythmia, diabetes, sleep apnea, and epilepsy. The coding discussions may provide the necessary momentum, said Stephen J. Ubl, AdvaMed president and CEO. The device lobby estimates that remote monitoring would cost $100 million or less over a 5-year period. Mr. Ubl also expressed hope that the Medicare package will include funds for a demonstration project to test a new payment system for certain molecular diagnostics. That would fix a flawed system, which pays less for new tests that may offer greater value to patients, he said. The pilot proposal is in S. 2404, which is sponsored by Sen. Chuck Schumer (D-N.Y.).

ACC on Vytorin Queries

The American College of Cardiology said it is cooperating with the House Energy and Commerce Committee on its requests to furnish information on funds the college has received from Merck & Co./Schering-Plough Corp., the joint venture that makes and sells Vytorin (ezetimibe/simvastatin). The drug combination has been the subject of intense scrutiny by the committee, largely because of delays in releasing data from the ENHANCE study. The committee said it wanted to know the nature of financial contributions made by the drug companies because the ACC and the American Heart Association had issued statements urging patients not to stop taking Vytorin without talking to their physicians first. The committee also requested data from the American Heart Association. Rep. Bart Stupak (D-Mich.), chairman of the oversight and investigations subcommittee, said his panel would look at “how they use this funding and any potential conflicts of interest.” An ACC spokesperson said the organization had delivered boxes of material to the committee, adding, “industry support in no way affects our policies.”

Endocrinologists descended on Washington last month to urge members of Congress to stop a potential Medicare payment cut for dual-energy x-ray absorptiometry exams.

Members of the American Association of Clinical Endocrinologists (AACE) are “very concerned” about the pending cut, said Dr. Jonathan Leffert, chairman of AACE's legislative and regulatory committee. “We think it will cause significant access problems for people who have osteoporosis.”

The current Medicare payment rate for a DXA scan is about $82, down from $140 in 2006, Dr. Leffert said. He noted that a survey from the Lewin Group put break-even reimbursement for a DXA scan at $139. “If the cuts are continued [as planned], by 2010, our estimates indicate Medicare will pay approximately $55 for DXA,” he said. “At $82 we're losing money, and at $55, it's untenable.”

Dr. Leffert said he already had heard from one New York physician who sold the two DXA machines he had in his office because he was losing too much money on the procedure. And Dr. Leffert said he himself recently had a patient who lived in a rural area try to get a DXA scan from a mobile unit that she had used in years past, only to find that it had gone out of business.

A DXA scan is one of the items included in the “Welcome to Medicare” physical exam, but many endocrinologists can't afford to provide the test because of the low reimbursement, Dr. Leffert said. He added that Medicare also does not allow physicians to balance bill patients to make up the difference between what they charge and what Medicare will pay.

The low DXA reimbursement “will have a significant effect in the long term because of [increased] fractures and the morbidity and mortality associated with that,” said Dr. Leffert, who is also in private practice in Dallas. “About 20%-25% of people who have hip fractures, for example, will die within a year due to related complications.”

The AACE members who participated in the association's annual Capitol Hill lobbying event were seeking support for H.R. 4206, the Medicare Fracture Prevention and Osteoporosis Testing Act of 2007. The bill, sponsored by Rep. Shelley Berkley (D-Nev.), would establish a national minimum payment amount for DXA as well as for vertebral fracture assessment, and would set the minimum payment amount at no less than 100% of the reimbursement rates in effect for those codes at the end of 2006 (about $140 in the case of DXA). It also would require the Institute of Medicine to report on the effects of DXA reimbursement cuts and to suggest methods to increase the use of bone mass measurement.

So far, the bill has 55 cosponsors, Dr. Leffert noted, adding that a Senate companion bill also will be introduced. The AACE delegation also sought support for H.R. 1293, sponsored by Rep. Carolyn McCarthy (D-N.Y.). That bill would put a 2-year moratorium on payment cuts for certain advanced imaging procedures. Sen. Jay Rockefeller (D-W.V.) has introduced a companion measure in the Senate.

The endocrinologists, who were joined by several members of the International Society for Clinical Densitometry, visited about 100 legislators, Dr. Leffert said.

Other issues the groups lobbied on include:

▸ Opposing additional Medicare reimbursement cuts for in-office ultrasound exams, including thyroid ultrasound, for which there already has been a significant decrease in reimbursement.

▸ Seeking a replacement for the sustainable growth rate (SGR) formula, which determines physician payment rates under Medicare. By law, officials at the Centers for Medicare and Medicaid Services must adjust physician payments according to the SGR, which calculates physician payment based in part on the gross domestic product.

“From our discussion with members of Congress, they all think there's going to be some fix [to the SGR],” said Dr. Leffert, who is also on the AACE board of directors. “Most of the [legislators] feel like it's going to be another short-term fix.”

Endocrinologists descended on Washington last month to urge members of Congress to stop a potential Medicare payment cut for dual-energy x-ray absorptiometry exams.

Members of the American Association of Clinical Endocrinologists (AACE) are “very concerned” about the pending cut, said Dr. Jonathan Leffert, chairman of AACE's legislative and regulatory committee. “We think it will cause significant access problems for people who have osteoporosis.”

The current Medicare payment rate for a DXA scan is about $82, down from $140 in 2006, Dr. Leffert said. He noted that a survey from the Lewin Group put break-even reimbursement for a DXA scan at $139. “If the cuts are continued [as planned], by 2010, our estimates indicate Medicare will pay approximately $55 for DXA,” he said. “At $82 we're losing money, and at $55, it's untenable.”

Dr. Leffert said he already had heard from one New York physician who sold the two DXA machines he had in his office because he was losing too much money on the procedure. And Dr. Leffert said he himself recently had a patient who lived in a rural area try to get a DXA scan from a mobile unit that she had used in years past, only to find that it had gone out of business.

A DXA scan is one of the items included in the “Welcome to Medicare” physical exam, but many endocrinologists can't afford to provide the test because of the low reimbursement, Dr. Leffert said. He added that Medicare also does not allow physicians to balance bill patients to make up the difference between what they charge and what Medicare will pay.

The low DXA reimbursement “will have a significant effect in the long term because of [increased] fractures and the morbidity and mortality associated with that,” said Dr. Leffert, who is also in private practice in Dallas. “About 20%-25% of people who have hip fractures, for example, will die within a year due to related complications.”

The AACE members who participated in the association's annual Capitol Hill lobbying event were seeking support for H.R. 4206, the Medicare Fracture Prevention and Osteoporosis Testing Act of 2007. The bill, sponsored by Rep. Shelley Berkley (D-Nev.), would establish a national minimum payment amount for DXA as well as for vertebral fracture assessment, and would set the minimum payment amount at no less than 100% of the reimbursement rates in effect for those codes at the end of 2006 (about $140 in the case of DXA). It also would require the Institute of Medicine to report on the effects of DXA reimbursement cuts and to suggest methods to increase the use of bone mass measurement.

So far, the bill has 55 cosponsors, Dr. Leffert noted, adding that a Senate companion bill also will be introduced. The AACE delegation also sought support for H.R. 1293, sponsored by Rep. Carolyn McCarthy (D-N.Y.). That bill would put a 2-year moratorium on payment cuts for certain advanced imaging procedures. Sen. Jay Rockefeller (D-W.V.) has introduced a companion measure in the Senate.

The endocrinologists, who were joined by several members of the International Society for Clinical Densitometry, visited about 100 legislators, Dr. Leffert said.

Other issues the groups lobbied on include:

▸ Opposing additional Medicare reimbursement cuts for in-office ultrasound exams, including thyroid ultrasound, for which there already has been a significant decrease in reimbursement.

▸ Seeking a replacement for the sustainable growth rate (SGR) formula, which determines physician payment rates under Medicare. By law, officials at the Centers for Medicare and Medicaid Services must adjust physician payments according to the SGR, which calculates physician payment based in part on the gross domestic product.

“From our discussion with members of Congress, they all think there's going to be some fix [to the SGR],” said Dr. Leffert, who is also on the AACE board of directors. “Most of the [legislators] feel like it's going to be another short-term fix.”

Endocrinologists descended on Washington last month to urge members of Congress to stop a potential Medicare payment cut for dual-energy x-ray absorptiometry exams.

Members of the American Association of Clinical Endocrinologists (AACE) are “very concerned” about the pending cut, said Dr. Jonathan Leffert, chairman of AACE's legislative and regulatory committee. “We think it will cause significant access problems for people who have osteoporosis.”

The current Medicare payment rate for a DXA scan is about $82, down from $140 in 2006, Dr. Leffert said. He noted that a survey from the Lewin Group put break-even reimbursement for a DXA scan at $139. “If the cuts are continued [as planned], by 2010, our estimates indicate Medicare will pay approximately $55 for DXA,” he said. “At $82 we're losing money, and at $55, it's untenable.”

Dr. Leffert said he already had heard from one New York physician who sold the two DXA machines he had in his office because he was losing too much money on the procedure. And Dr. Leffert said he himself recently had a patient who lived in a rural area try to get a DXA scan from a mobile unit that she had used in years past, only to find that it had gone out of business.

A DXA scan is one of the items included in the “Welcome to Medicare” physical exam, but many endocrinologists can't afford to provide the test because of the low reimbursement, Dr. Leffert said. He added that Medicare also does not allow physicians to balance bill patients to make up the difference between what they charge and what Medicare will pay.

The low DXA reimbursement “will have a significant effect in the long term because of [increased] fractures and the morbidity and mortality associated with that,” said Dr. Leffert, who is also in private practice in Dallas. “About 20%-25% of people who have hip fractures, for example, will die within a year due to related complications.”

The AACE members who participated in the association's annual Capitol Hill lobbying event were seeking support for H.R. 4206, the Medicare Fracture Prevention and Osteoporosis Testing Act of 2007. The bill, sponsored by Rep. Shelley Berkley (D-Nev.), would establish a national minimum payment amount for DXA as well as for vertebral fracture assessment, and would set the minimum payment amount at no less than 100% of the reimbursement rates in effect for those codes at the end of 2006 (about $140 in the case of DXA). It also would require the Institute of Medicine to report on the effects of DXA reimbursement cuts and to suggest methods to increase the use of bone mass measurement.

So far, the bill has 55 cosponsors, Dr. Leffert noted, adding that a Senate companion bill also will be introduced. The AACE delegation also sought support for H.R. 1293, sponsored by Rep. Carolyn McCarthy (D-N.Y.). That bill would put a 2-year moratorium on payment cuts for certain advanced imaging procedures. Sen. Jay Rockefeller (D-W.V.) has introduced a companion measure in the Senate.

The endocrinologists, who were joined by several members of the International Society for Clinical Densitometry, visited about 100 legislators, Dr. Leffert said.

Other issues the groups lobbied on include:

▸ Opposing additional Medicare reimbursement cuts for in-office ultrasound exams, including thyroid ultrasound, for which there already has been a significant decrease in reimbursement.

▸ Seeking a replacement for the sustainable growth rate (SGR) formula, which determines physician payment rates under Medicare. By law, officials at the Centers for Medicare and Medicaid Services must adjust physician payments according to the SGR, which calculates physician payment based in part on the gross domestic product.

“From our discussion with members of Congress, they all think there's going to be some fix [to the SGR],” said Dr. Leffert, who is also on the AACE board of directors. “Most of the [legislators] feel like it's going to be another short-term fix.”

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory.

“I don't think there should be a mandate for every American to have health insurance,” the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals. “If it's affordable and available, then it seems to me it's a matter of choice amongst Americans,” he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. “The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to” sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, “and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage.”

Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. “I'm not going to force Americans to do it; I don't think that's the role of government,” he said. “But if we can bring down costs, as I believe we can … I'm absolutely convinced more and more people will take advantage of [health insurance].”

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. “Right now we pay for every single procedure—the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers.”

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits—which would cost the government an estimated $3.5 trillion over 10 years—he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction that employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

“The important thing about the … refundable tax credit for employees is for them to go out and make choices,” Sen. McCain said during the forum. “When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else.” And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year—far higher than the amount of the proposed family tax credit—Sen. McCain said the credit still would be beneficial. “One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan,” he said. “Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it].” The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the “cherry-picking” that some health plans do to make certain they insure mostly healthy people. Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents. “I would rather go that route than mandate that health insurance companies under any condition would have to accept a certain level of patients.”

A 'very large portion' of the uninsured 'are healthy young Americans who simply choose not to' sign up for it. SEN. MCCAIN

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory.

“I don't think there should be a mandate for every American to have health insurance,” the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals. “If it's affordable and available, then it seems to me it's a matter of choice amongst Americans,” he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. “The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to” sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, “and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage.”

Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. “I'm not going to force Americans to do it; I don't think that's the role of government,” he said. “But if we can bring down costs, as I believe we can … I'm absolutely convinced more and more people will take advantage of [health insurance].”

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. “Right now we pay for every single procedure—the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers.”

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits—which would cost the government an estimated $3.5 trillion over 10 years—he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction that employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

“The important thing about the … refundable tax credit for employees is for them to go out and make choices,” Sen. McCain said during the forum. “When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else.” And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year—far higher than the amount of the proposed family tax credit—Sen. McCain said the credit still would be beneficial. “One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan,” he said. “Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it].” The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the “cherry-picking” that some health plans do to make certain they insure mostly healthy people. Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents. “I would rather go that route than mandate that health insurance companies under any condition would have to accept a certain level of patients.”

A 'very large portion' of the uninsured 'are healthy young Americans who simply choose not to' sign up for it. SEN. MCCAIN

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory.

“I don't think there should be a mandate for every American to have health insurance,” the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals. “If it's affordable and available, then it seems to me it's a matter of choice amongst Americans,” he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. “The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to” sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, “and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage.”

Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. “I'm not going to force Americans to do it; I don't think that's the role of government,” he said. “But if we can bring down costs, as I believe we can … I'm absolutely convinced more and more people will take advantage of [health insurance].”

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. “Right now we pay for every single procedure—the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers.”

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits—which would cost the government an estimated $3.5 trillion over 10 years—he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction that employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

“The important thing about the … refundable tax credit for employees is for them to go out and make choices,” Sen. McCain said during the forum. “When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else.” And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year—far higher than the amount of the proposed family tax credit—Sen. McCain said the credit still would be beneficial. “One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan,” he said. “Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it].” The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the “cherry-picking” that some health plans do to make certain they insure mostly healthy people. Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents. “I would rather go that route than mandate that health insurance companies under any condition would have to accept a certain level of patients.”

A 'very large portion' of the uninsured 'are healthy young Americans who simply choose not to' sign up for it. SEN. MCCAIN

ST. LOUIS – In addition to problems with health literacy in general, diabetes patients are especially susceptible to problems with a specific aspect of health literacy known as health numeracy.

Numeracy is the ability to understand and use numbers and math skills in daily life. Diabetes requires a lot of health numeracy skills–calculating insulin dosages, counting carbohydrates, calculating ratios for combination insulin regimens, and sick day management, Dr. Russell Rothman said at the annual meeting of the American Association of Diabetes Educators.

Dr. Rothman, director of the Effective Health Communication Program at Vanderbilt University, Nashville, Tenn., and his colleagues tested 398 diabetes patients using a 43-item examination. The patient population was 51% female, and the average age was 54 years; 14% of the patients had type 1 diabetes, and 86% had type 2 diabetes. In terms of education, 43% of the participants had no more than a high school education, and 69% had less than ninth-grade math skills as measured by the Wide Range Achievement Test.

The researchers sought to evaluate patients' ability to count carbohydrates, interpret glucose meter results, apply sliding-scale insulin regimens, calculate insulin dosage based on insulin to carbohydrate intake, and use other diabetes-related numeracy skills. They looked at the relationship between the test score and patients' hemoglobin A1c (HbA_1c) levels, and other outcomes.

Patients correctly answered an average of 61% of the test questions. Problem areas included interpreting serving sizes from food labels, using fractions and decimals, and dealing with multiple-step problems (adjusting for blood sugar and carbohydrates at the same time)

Every 10-point increase on the numeracy test translated into an average 0.1% decrease in HbA_1c, after adjusting for age, gender, race, income, literacy, insulin status, and type of diabetes. Higher test scores were significantly correlated with higher educational status, literacy, math skills, and frequency of blood glucose monitoring.

Many people aren't good at estimating portion sizes, which causes difficulty when it comes to estimating insulin dosages correctly, said Dr. Rothman. “That brings home the importance of using measuring devices in diabetes education.”

ST. LOUIS – In addition to problems with health literacy in general, diabetes patients are especially susceptible to problems with a specific aspect of health literacy known as health numeracy.

Numeracy is the ability to understand and use numbers and math skills in daily life. Diabetes requires a lot of health numeracy skills–calculating insulin dosages, counting carbohydrates, calculating ratios for combination insulin regimens, and sick day management, Dr. Russell Rothman said at the annual meeting of the American Association of Diabetes Educators.

Dr. Rothman, director of the Effective Health Communication Program at Vanderbilt University, Nashville, Tenn., and his colleagues tested 398 diabetes patients using a 43-item examination. The patient population was 51% female, and the average age was 54 years; 14% of the patients had type 1 diabetes, and 86% had type 2 diabetes. In terms of education, 43% of the participants had no more than a high school education, and 69% had less than ninth-grade math skills as measured by the Wide Range Achievement Test.

The researchers sought to evaluate patients' ability to count carbohydrates, interpret glucose meter results, apply sliding-scale insulin regimens, calculate insulin dosage based on insulin to carbohydrate intake, and use other diabetes-related numeracy skills. They looked at the relationship between the test score and patients' hemoglobin A1c (HbA_1c) levels, and other outcomes.

Patients correctly answered an average of 61% of the test questions. Problem areas included interpreting serving sizes from food labels, using fractions and decimals, and dealing with multiple-step problems (adjusting for blood sugar and carbohydrates at the same time)

Every 10-point increase on the numeracy test translated into an average 0.1% decrease in HbA_1c, after adjusting for age, gender, race, income, literacy, insulin status, and type of diabetes. Higher test scores were significantly correlated with higher educational status, literacy, math skills, and frequency of blood glucose monitoring.

Many people aren't good at estimating portion sizes, which causes difficulty when it comes to estimating insulin dosages correctly, said Dr. Rothman. “That brings home the importance of using measuring devices in diabetes education.”

ST. LOUIS – In addition to problems with health literacy in general, diabetes patients are especially susceptible to problems with a specific aspect of health literacy known as health numeracy.

Numeracy is the ability to understand and use numbers and math skills in daily life. Diabetes requires a lot of health numeracy skills–calculating insulin dosages, counting carbohydrates, calculating ratios for combination insulin regimens, and sick day management, Dr. Russell Rothman said at the annual meeting of the American Association of Diabetes Educators.

Dr. Rothman, director of the Effective Health Communication Program at Vanderbilt University, Nashville, Tenn., and his colleagues tested 398 diabetes patients using a 43-item examination. The patient population was 51% female, and the average age was 54 years; 14% of the patients had type 1 diabetes, and 86% had type 2 diabetes. In terms of education, 43% of the participants had no more than a high school education, and 69% had less than ninth-grade math skills as measured by the Wide Range Achievement Test.

The researchers sought to evaluate patients' ability to count carbohydrates, interpret glucose meter results, apply sliding-scale insulin regimens, calculate insulin dosage based on insulin to carbohydrate intake, and use other diabetes-related numeracy skills. They looked at the relationship between the test score and patients' hemoglobin A1c (HbA_1c) levels, and other outcomes.

Patients correctly answered an average of 61% of the test questions. Problem areas included interpreting serving sizes from food labels, using fractions and decimals, and dealing with multiple-step problems (adjusting for blood sugar and carbohydrates at the same time)

Every 10-point increase on the numeracy test translated into an average 0.1% decrease in HbA_1c, after adjusting for age, gender, race, income, literacy, insulin status, and type of diabetes. Higher test scores were significantly correlated with higher educational status, literacy, math skills, and frequency of blood glucose monitoring.

Many people aren't good at estimating portion sizes, which causes difficulty when it comes to estimating insulin dosages correctly, said Dr. Rothman. “That brings home the importance of using measuring devices in diabetes education.”

Bergenstal Elected to ADA Post

Dr. Richard M. Bergenstal is the new vice president for medicine and science at the American Diabetes Association. Dr. Bergenstal, a researcher who focuses on the link between glucose control and diabetes complications, previously served on the ADA's board of directors as well as several association committees. He also previously chaired the association's Council on Clinical Endocrinology, Health Care Delivery, and Public Health. Dr. Bergenstal is executive director of the International Diabetes Center at Park Nicollet in Minneapolis and clinical professor of medicine at the University of Minnesota.

Questions About BTC Drugs

The House Energy and Commerce Committee is investigating the wisdom of behind-the-counter drug dispensing. The committee has asked the Government Accountability Office to update a study it conducted in 1995, “Nonprescription Drugs: Value of a Pharmacist-Controlled Class Has Yet to Be Demonstrated.” At a November public meeting on the subject, the agency said it had no intention of establishing a new BTC class in the immediate future.

Scant Number of New Approvals

The FDA approved only 17 new molecular entities (NMEs) in 2007, the lowest number since 2002. This comes on the heels of 2 previous years with only 18 NME approvals each. NMEs are unique products. Those approved in 2007 included two HIV therapies, four oncology products, two antihypertensives, one antibiotic, and one each to treat Parkinson's disease, pulmonary hypertension, impetigo, acromegaly, attention-deficit hyperactivity disorder, and phenylketonuria. Also approved were an imaging agent and injection to prevent blood volume loss during surgery, a handful of biologics, an influenza vaccine, and an avian flu vaccine.

Docs Mistrust Error Reporting Systems

U.S. physicians are willing to report medical errors but don't trust the current error reporting systems, according to a study in the January/February issue of Health Affairs. Between July 2003 and March 2004, researchers surveyed more than 1,000 physicians in rural and urban areas of Missouri and Washington state. They found that because of their mistrust of current systems, most physicians rely on informal discussion with colleagues as a way to report and share information about errors. Most physicians also reported that they had been involved in an error–56% with a serious error, 74% with a minor error, and 66% with a “near miss.” When asked what would increase their willingness to formally report errors, 88% said they wanted information to be kept confidential and nondiscoverable, 85% wanted evidence that error information would be used for system improvements, and 53% said they wanted review activities confined to their department. “These findings shed light on an important question–how to create error-reporting programs that will encourage clinician participation,” said Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality, which funded the study. “Physicians say they want to learn from errors that take place in their institution. We need to build on that willingness with error-reporting programs that encourage their participation.”

Judge Overturns Rx Info Law

A federal judge has overturned a Maine law that would have restricted medical data companies' access to physician prescribing information. In a decision that relied heavily on a previous ruling in New Hampshire, U.S. District Judge John Woodcock said that the law would prohibit “the transfer of truthful commercial information” and would violate the free speech guarantee of the First Amendment. The Maine law was challenged on constitutional grounds by IMS Health, Wolters Kluwer Health, and Verispan, all medical data companies that collect, analyze, and sell such data to pharmaceutical manufacturers. The companies also argued that the law bucks a national trend toward greater transparency in health care information.

FDA Cancels DTC User Fee Program

The Food and Drug Administration recently announced that it is pulling the plug on a voluntary user fee program for direct-to-consumer television advertisements. The agency had planned to charge pharmaceutical companies about $40,000 per ad to review their DTC television spots. But in January, the FDA issued a notice saying that it would not go forward with the user fee program because no money was appropriated for the program in the fiscal year 2008 consolidated appropriations bill. Under the law that authorized the program, the agency can collect fees only up to the amount provided in advance by congressional appropriations. As a result, the FDA plans to review any ads already submitted at no charge, as resources will allow.

Bergenstal Elected to ADA Post

Dr. Richard M. Bergenstal is the new vice president for medicine and science at the American Diabetes Association. Dr. Bergenstal, a researcher who focuses on the link between glucose control and diabetes complications, previously served on the ADA's board of directors as well as several association committees. He also previously chaired the association's Council on Clinical Endocrinology, Health Care Delivery, and Public Health. Dr. Bergenstal is executive director of the International Diabetes Center at Park Nicollet in Minneapolis and clinical professor of medicine at the University of Minnesota.

Questions About BTC Drugs

The House Energy and Commerce Committee is investigating the wisdom of behind-the-counter drug dispensing. The committee has asked the Government Accountability Office to update a study it conducted in 1995, “Nonprescription Drugs: Value of a Pharmacist-Controlled Class Has Yet to Be Demonstrated.” At a November public meeting on the subject, the agency said it had no intention of establishing a new BTC class in the immediate future.

Scant Number of New Approvals

The FDA approved only 17 new molecular entities (NMEs) in 2007, the lowest number since 2002. This comes on the heels of 2 previous years with only 18 NME approvals each. NMEs are unique products. Those approved in 2007 included two HIV therapies, four oncology products, two antihypertensives, one antibiotic, and one each to treat Parkinson's disease, pulmonary hypertension, impetigo, acromegaly, attention-deficit hyperactivity disorder, and phenylketonuria. Also approved were an imaging agent and injection to prevent blood volume loss during surgery, a handful of biologics, an influenza vaccine, and an avian flu vaccine.

Docs Mistrust Error Reporting Systems

U.S. physicians are willing to report medical errors but don't trust the current error reporting systems, according to a study in the January/February issue of Health Affairs. Between July 2003 and March 2004, researchers surveyed more than 1,000 physicians in rural and urban areas of Missouri and Washington state. They found that because of their mistrust of current systems, most physicians rely on informal discussion with colleagues as a way to report and share information about errors. Most physicians also reported that they had been involved in an error–56% with a serious error, 74% with a minor error, and 66% with a “near miss.” When asked what would increase their willingness to formally report errors, 88% said they wanted information to be kept confidential and nondiscoverable, 85% wanted evidence that error information would be used for system improvements, and 53% said they wanted review activities confined to their department. “These findings shed light on an important question–how to create error-reporting programs that will encourage clinician participation,” said Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality, which funded the study. “Physicians say they want to learn from errors that take place in their institution. We need to build on that willingness with error-reporting programs that encourage their participation.”

Judge Overturns Rx Info Law

A federal judge has overturned a Maine law that would have restricted medical data companies' access to physician prescribing information. In a decision that relied heavily on a previous ruling in New Hampshire, U.S. District Judge John Woodcock said that the law would prohibit “the transfer of truthful commercial information” and would violate the free speech guarantee of the First Amendment. The Maine law was challenged on constitutional grounds by IMS Health, Wolters Kluwer Health, and Verispan, all medical data companies that collect, analyze, and sell such data to pharmaceutical manufacturers. The companies also argued that the law bucks a national trend toward greater transparency in health care information.

FDA Cancels DTC User Fee Program

The Food and Drug Administration recently announced that it is pulling the plug on a voluntary user fee program for direct-to-consumer television advertisements. The agency had planned to charge pharmaceutical companies about $40,000 per ad to review their DTC television spots. But in January, the FDA issued a notice saying that it would not go forward with the user fee program because no money was appropriated for the program in the fiscal year 2008 consolidated appropriations bill. Under the law that authorized the program, the agency can collect fees only up to the amount provided in advance by congressional appropriations. As a result, the FDA plans to review any ads already submitted at no charge, as resources will allow.

Bergenstal Elected to ADA Post

Dr. Richard M. Bergenstal is the new vice president for medicine and science at the American Diabetes Association. Dr. Bergenstal, a researcher who focuses on the link between glucose control and diabetes complications, previously served on the ADA's board of directors as well as several association committees. He also previously chaired the association's Council on Clinical Endocrinology, Health Care Delivery, and Public Health. Dr. Bergenstal is executive director of the International Diabetes Center at Park Nicollet in Minneapolis and clinical professor of medicine at the University of Minnesota.

Questions About BTC Drugs

The House Energy and Commerce Committee is investigating the wisdom of behind-the-counter drug dispensing. The committee has asked the Government Accountability Office to update a study it conducted in 1995, “Nonprescription Drugs: Value of a Pharmacist-Controlled Class Has Yet to Be Demonstrated.” At a November public meeting on the subject, the agency said it had no intention of establishing a new BTC class in the immediate future.

Scant Number of New Approvals

The FDA approved only 17 new molecular entities (NMEs) in 2007, the lowest number since 2002. This comes on the heels of 2 previous years with only 18 NME approvals each. NMEs are unique products. Those approved in 2007 included two HIV therapies, four oncology products, two antihypertensives, one antibiotic, and one each to treat Parkinson's disease, pulmonary hypertension, impetigo, acromegaly, attention-deficit hyperactivity disorder, and phenylketonuria. Also approved were an imaging agent and injection to prevent blood volume loss during surgery, a handful of biologics, an influenza vaccine, and an avian flu vaccine.

Docs Mistrust Error Reporting Systems

U.S. physicians are willing to report medical errors but don't trust the current error reporting systems, according to a study in the January/February issue of Health Affairs. Between July 2003 and March 2004, researchers surveyed more than 1,000 physicians in rural and urban areas of Missouri and Washington state. They found that because of their mistrust of current systems, most physicians rely on informal discussion with colleagues as a way to report and share information about errors. Most physicians also reported that they had been involved in an error–56% with a serious error, 74% with a minor error, and 66% with a “near miss.” When asked what would increase their willingness to formally report errors, 88% said they wanted information to be kept confidential and nondiscoverable, 85% wanted evidence that error information would be used for system improvements, and 53% said they wanted review activities confined to their department. “These findings shed light on an important question–how to create error-reporting programs that will encourage clinician participation,” said Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality, which funded the study. “Physicians say they want to learn from errors that take place in their institution. We need to build on that willingness with error-reporting programs that encourage their participation.”

Judge Overturns Rx Info Law

A federal judge has overturned a Maine law that would have restricted medical data companies' access to physician prescribing information. In a decision that relied heavily on a previous ruling in New Hampshire, U.S. District Judge John Woodcock said that the law would prohibit “the transfer of truthful commercial information” and would violate the free speech guarantee of the First Amendment. The Maine law was challenged on constitutional grounds by IMS Health, Wolters Kluwer Health, and Verispan, all medical data companies that collect, analyze, and sell such data to pharmaceutical manufacturers. The companies also argued that the law bucks a national trend toward greater transparency in health care information.

FDA Cancels DTC User Fee Program

The Food and Drug Administration recently announced that it is pulling the plug on a voluntary user fee program for direct-to-consumer television advertisements. The agency had planned to charge pharmaceutical companies about $40,000 per ad to review their DTC television spots. But in January, the FDA issued a notice saying that it would not go forward with the user fee program because no money was appropriated for the program in the fiscal year 2008 consolidated appropriations bill. Under the law that authorized the program, the agency can collect fees only up to the amount provided in advance by congressional appropriations. As a result, the FDA plans to review any ads already submitted at no charge, as resources will allow.

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory.

“I don't think there should be a mandate for every American to have health insurance,” the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals. “I think one of our goals should be that every American own their own home, but I'm not going to mandate that. … I feel the same way about health care. If it's affordable and available, then it seems to me it's a matter of choice amongst Americans,” he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. “The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to” sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, “and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage.”

Instead of mandating that people have health insurance, Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. “I'm not going to force Americans to do it; I don't think that's the role of government,” he said. “But if we can bring down costs, as I believe we can … I'm absolutely convinced more and more people will take advantage of [health insurance]. The panacea isn't all just health care costs, but unless you address health care costs, you're never going to solve the other aspects of the health care crisis.”

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. “Right now we pay for every single procedure–the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers.”

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits–which would cost the government an estimated $3.5 trillion over 10 years–he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

“The important thing about the … refundable tax credit for employees is for them to go out and make choices,” Sen. McCain said during the forum. “When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else.” And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year–far higher than the amount of the proposed family tax credit–Sen. McCain said the credit still would be beneficial. “One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan,” he said. “Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it].”

Sen. McCain admitted that the tax credit plan “is not a perfect solution, and if not for the price tag involved, I'd make it even higher. But according to the Congressional Budget Office, by shifting the employee tax aspect of it, you save $3.5 trillion over a 10-year period, and I think that would have some beneficial effect at reducing the overall health care cost burden that we're laying on future generations.” The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the “cherry-picking” that some health plans do to make certain they insure mostly healthy people. Outlawing cherry-picking “would be mandating what the free enterprise system does and that would be obviously something that I would not approve of.” Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents.

'We should be paying … the doctor a certain set amount of money … related to overall care and results.' SEN. MCCAIN

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory.

“I don't think there should be a mandate for every American to have health insurance,” the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals. “I think one of our goals should be that every American own their own home, but I'm not going to mandate that. … I feel the same way about health care. If it's affordable and available, then it seems to me it's a matter of choice amongst Americans,” he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. “The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to” sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, “and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage.”

Instead of mandating that people have health insurance, Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. “I'm not going to force Americans to do it; I don't think that's the role of government,” he said. “But if we can bring down costs, as I believe we can … I'm absolutely convinced more and more people will take advantage of [health insurance]. The panacea isn't all just health care costs, but unless you address health care costs, you're never going to solve the other aspects of the health care crisis.”

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. “Right now we pay for every single procedure–the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers.”

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits–which would cost the government an estimated $3.5 trillion over 10 years–he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

“The important thing about the … refundable tax credit for employees is for them to go out and make choices,” Sen. McCain said during the forum. “When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else.” And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year–far higher than the amount of the proposed family tax credit–Sen. McCain said the credit still would be beneficial. “One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan,” he said. “Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it].”

Sen. McCain admitted that the tax credit plan “is not a perfect solution, and if not for the price tag involved, I'd make it even higher. But according to the Congressional Budget Office, by shifting the employee tax aspect of it, you save $3.5 trillion over a 10-year period, and I think that would have some beneficial effect at reducing the overall health care cost burden that we're laying on future generations.” The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the “cherry-picking” that some health plans do to make certain they insure mostly healthy people. Outlawing cherry-picking “would be mandating what the free enterprise system does and that would be obviously something that I would not approve of.” Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents.

'We should be paying … the doctor a certain set amount of money … related to overall care and results.' SEN. MCCAIN

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory.

“I don't think there should be a mandate for every American to have health insurance,” the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals. “I think one of our goals should be that every American own their own home, but I'm not going to mandate that. … I feel the same way about health care. If it's affordable and available, then it seems to me it's a matter of choice amongst Americans,” he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. “The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to” sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, “and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage.”

Instead of mandating that people have health insurance, Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. “I'm not going to force Americans to do it; I don't think that's the role of government,” he said. “But if we can bring down costs, as I believe we can … I'm absolutely convinced more and more people will take advantage of [health insurance]. The panacea isn't all just health care costs, but unless you address health care costs, you're never going to solve the other aspects of the health care crisis.”

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. “Right now we pay for every single procedure–the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers.”

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits–which would cost the government an estimated $3.5 trillion over 10 years–he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

“The important thing about the … refundable tax credit for employees is for them to go out and make choices,” Sen. McCain said during the forum. “When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else.” And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year–far higher than the amount of the proposed family tax credit–Sen. McCain said the credit still would be beneficial. “One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan,” he said. “Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it].”

Sen. McCain admitted that the tax credit plan “is not a perfect solution, and if not for the price tag involved, I'd make it even higher. But according to the Congressional Budget Office, by shifting the employee tax aspect of it, you save $3.5 trillion over a 10-year period, and I think that would have some beneficial effect at reducing the overall health care cost burden that we're laying on future generations.” The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the “cherry-picking” that some health plans do to make certain they insure mostly healthy people. Outlawing cherry-picking “would be mandating what the free enterprise system does and that would be obviously something that I would not approve of.” Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents.

'We should be paying … the doctor a certain set amount of money … related to overall care and results.' SEN. MCCAIN

WASHINGTON – According to Sen. Hillary Rodham Clinton (D-N.Y.), primary care physicians don't get enough pay or respect, and there aren't enough of them. Her response to the problem? The federal government should try to help increase the supply of primary care doctors, but in the meantime nurses, pharmacists, and others should fill the gaps in care.

“I'm intrigued by the fact that a lot of states are permitting pharmacists to give vaccines,” Sen. Clinton, a candidate for the Democratic presidential nomination, said at a health policy forum sponsored by Families USA and the Federation of American Hospitals. “What other functions can we delegate out, given appropriate oversight and training?”

For example, she said, “I think nurses have a great opportunity to do much more than they're doing. If we're not going to be able to quickly increase the number of primary care physicians, we need more advanced practice nurses, and they've got to be given the authority to make some of these [treatment] decisions, because otherwise people will go without care.”

Sen. Clinton, who is in her second Senate term, said that health care would be her top domestic priority if she were elected president.

“This is, for me, a moral question and an economic one,” she said. “Do we want to continue to be so unequal and unfair that, if you are uninsured and you go into the hospital with someone who is insured, you are more likely to die?”

Sen. Clinton said she learned a lot from her experience in her husband's first presidential term when she led his efforts to develop a universal health care plan.

“The fact that the White House took on the responsibility of writing the legislation turned out to be something of a mistake,” she said at the forum, part of a series of presidential candidate health policy forums underwritten by the California Endowment and the Ewing Marion Kauffman Foundation.

She said that now she sees the president's role on health care as “setting the goals and framework but not getting into the details.”

Further, the Clinton plan of the early 1990s was just too complicated, she said. “It was a source of concern to a lot of Americans who didn't understand how it could work, and it certainly wasn't presented in the best way.”

This time, Sen. Clinton has a different plan. The “American Health Choices Plan” would allow people to keep their current insurance coverage, but if they didn't like their current insurance or were uninsured, they could choose from a variety of plans similar to those offered to federal employees. They would also have the option of enrolling in a public plan similar to Medicare.

Sen. Clinton said coverage under her plan would be affordable and fully portable, and that insurers would be barred from discriminating against enrollees based on preexisting conditions.

Large employers would be required to offer coverage or help pay for employee health care; small businesses would not be required to offer coverage, but they would be given tax credits to encourage them to do so.

She estimated the cost of her plan at $110 billion per year and said it would be paid for by rolling back tax breaks for Americans who make more than $250,000 annually.

Sen. Clinton said critics who called her plan a back door to a single-payer, government-run health care system were either misinformed or were misrepresenting her proposal.

“I've included the public plan option because a lot of Americans want it,” she said. “It will not create a new bureaucracy; it will not create a government-run system unless you think Medicare is government run. In Medicare, you choose your doctor, you choose your hospital–you have tremendous choice.”

Sen. Clinton predicted that a lot of people would still choose a private plan because “if the private plans are competitive and smart, they'll offer a lot of new features. What are we afraid of? Let's see where competition leads us.”

Sen. Clinton also expressed her support of the increased use of electronic health records to make the health care system more organized. “It's very hard to think about having a system when you don't have any way for people to move [their records with them] from place to place and job to job.”

Paying providers based on their outcomes was another recent innovation mentioned by Sen. Clinton. She lauded the Bush administration for announcing that the Medicare program would no longer pay for care occurring as a result of medical errors. “That kind of connection between pay and performance, quality and results … makes sense. It's hard to do, but we have to experiment.”

The recent increase in cases of nosocomial infections such as methicillin-resistant Staphylococcus aureus “should be a wake-up call for everybody,” Sen. Clinton said. “A couple of hospitals I'm aware of have changed their infection control policies; they have cut the rate of hospital-borne infections. Everybody should be expected to do that.”

'I'm intrigued by the fact that a lot of states are permitting pharmacists to give vaccines.' SEN. CLINTON

WASHINGTON – According to Sen. Hillary Rodham Clinton (D-N.Y.), primary care physicians don't get enough pay or respect, and there aren't enough of them. Her response to the problem? The federal government should try to help increase the supply of primary care doctors, but in the meantime nurses, pharmacists, and others should fill the gaps in care.

“I'm intrigued by the fact that a lot of states are permitting pharmacists to give vaccines,” Sen. Clinton, a candidate for the Democratic presidential nomination, said at a health policy forum sponsored by Families USA and the Federation of American Hospitals. “What other functions can we delegate out, given appropriate oversight and training?”

For example, she said, “I think nurses have a great opportunity to do much more than they're doing. If we're not going to be able to quickly increase the number of primary care physicians, we need more advanced practice nurses, and they've got to be given the authority to make some of these [treatment] decisions, because otherwise people will go without care.”

Sen. Clinton, who is in her second Senate term, said that health care would be her top domestic priority if she were elected president.

“This is, for me, a moral question and an economic one,” she said. “Do we want to continue to be so unequal and unfair that, if you are uninsured and you go into the hospital with someone who is insured, you are more likely to die?”

Sen. Clinton said she learned a lot from her experience in her husband's first presidential term when she led his efforts to develop a universal health care plan.

“The fact that the White House took on the responsibility of writing the legislation turned out to be something of a mistake,” she said at the forum, part of a series of presidential candidate health policy forums underwritten by the California Endowment and the Ewing Marion Kauffman Foundation.

She said that now she sees the president's role on health care as “setting the goals and framework but not getting into the details.”

Further, the Clinton plan of the early 1990s was just too complicated, she said. “It was a source of concern to a lot of Americans who didn't understand how it could work, and it certainly wasn't presented in the best way.”

This time, Sen. Clinton has a different plan. The “American Health Choices Plan” would allow people to keep their current insurance coverage, but if they didn't like their current insurance or were uninsured, they could choose from a variety of plans similar to those offered to federal employees. They would also have the option of enrolling in a public plan similar to Medicare.

Sen. Clinton said coverage under her plan would be affordable and fully portable, and that insurers would be barred from discriminating against enrollees based on preexisting conditions.

Large employers would be required to offer coverage or help pay for employee health care; small businesses would not be required to offer coverage, but they would be given tax credits to encourage them to do so.

She estimated the cost of her plan at $110 billion per year and said it would be paid for by rolling back tax breaks for Americans who make more than $250,000 annually.

Sen. Clinton said critics who called her plan a back door to a single-payer, government-run health care system were either misinformed or were misrepresenting her proposal.

“I've included the public plan option because a lot of Americans want it,” she said. “It will not create a new bureaucracy; it will not create a government-run system unless you think Medicare is government run. In Medicare, you choose your doctor, you choose your hospital–you have tremendous choice.”

Sen. Clinton predicted that a lot of people would still choose a private plan because “if the private plans are competitive and smart, they'll offer a lot of new features. What are we afraid of? Let's see where competition leads us.”

Sen. Clinton also expressed her support of the increased use of electronic health records to make the health care system more organized. “It's very hard to think about having a system when you don't have any way for people to move [their records with them] from place to place and job to job.”

Paying providers based on their outcomes was another recent innovation mentioned by Sen. Clinton. She lauded the Bush administration for announcing that the Medicare program would no longer pay for care occurring as a result of medical errors. “That kind of connection between pay and performance, quality and results … makes sense. It's hard to do, but we have to experiment.”

The recent increase in cases of nosocomial infections such as methicillin-resistant Staphylococcus aureus “should be a wake-up call for everybody,” Sen. Clinton said. “A couple of hospitals I'm aware of have changed their infection control policies; they have cut the rate of hospital-borne infections. Everybody should be expected to do that.”

'I'm intrigued by the fact that a lot of states are permitting pharmacists to give vaccines.' SEN. CLINTON

WASHINGTON – According to Sen. Hillary Rodham Clinton (D-N.Y.), primary care physicians don't get enough pay or respect, and there aren't enough of them. Her response to the problem? The federal government should try to help increase the supply of primary care doctors, but in the meantime nurses, pharmacists, and others should fill the gaps in care.

“I'm intrigued by the fact that a lot of states are permitting pharmacists to give vaccines,” Sen. Clinton, a candidate for the Democratic presidential nomination, said at a health policy forum sponsored by Families USA and the Federation of American Hospitals. “What other functions can we delegate out, given appropriate oversight and training?”

For example, she said, “I think nurses have a great opportunity to do much more than they're doing. If we're not going to be able to quickly increase the number of primary care physicians, we need more advanced practice nurses, and they've got to be given the authority to make some of these [treatment] decisions, because otherwise people will go without care.”

Sen. Clinton, who is in her second Senate term, said that health care would be her top domestic priority if she were elected president.

“This is, for me, a moral question and an economic one,” she said. “Do we want to continue to be so unequal and unfair that, if you are uninsured and you go into the hospital with someone who is insured, you are more likely to die?”

Sen. Clinton said she learned a lot from her experience in her husband's first presidential term when she led his efforts to develop a universal health care plan.

“The fact that the White House took on the responsibility of writing the legislation turned out to be something of a mistake,” she said at the forum, part of a series of presidential candidate health policy forums underwritten by the California Endowment and the Ewing Marion Kauffman Foundation.

She said that now she sees the president's role on health care as “setting the goals and framework but not getting into the details.”

Further, the Clinton plan of the early 1990s was just too complicated, she said. “It was a source of concern to a lot of Americans who didn't understand how it could work, and it certainly wasn't presented in the best way.”

This time, Sen. Clinton has a different plan. The “American Health Choices Plan” would allow people to keep their current insurance coverage, but if they didn't like their current insurance or were uninsured, they could choose from a variety of plans similar to those offered to federal employees. They would also have the option of enrolling in a public plan similar to Medicare.

Sen. Clinton said coverage under her plan would be affordable and fully portable, and that insurers would be barred from discriminating against enrollees based on preexisting conditions.

Large employers would be required to offer coverage or help pay for employee health care; small businesses would not be required to offer coverage, but they would be given tax credits to encourage them to do so.

She estimated the cost of her plan at $110 billion per year and said it would be paid for by rolling back tax breaks for Americans who make more than $250,000 annually.

Sen. Clinton said critics who called her plan a back door to a single-payer, government-run health care system were either misinformed or were misrepresenting her proposal.

“I've included the public plan option because a lot of Americans want it,” she said. “It will not create a new bureaucracy; it will not create a government-run system unless you think Medicare is government run. In Medicare, you choose your doctor, you choose your hospital–you have tremendous choice.”

Sen. Clinton predicted that a lot of people would still choose a private plan because “if the private plans are competitive and smart, they'll offer a lot of new features. What are we afraid of? Let's see where competition leads us.”

Sen. Clinton also expressed her support of the increased use of electronic health records to make the health care system more organized. “It's very hard to think about having a system when you don't have any way for people to move [their records with them] from place to place and job to job.”

Paying providers based on their outcomes was another recent innovation mentioned by Sen. Clinton. She lauded the Bush administration for announcing that the Medicare program would no longer pay for care occurring as a result of medical errors. “That kind of connection between pay and performance, quality and results … makes sense. It's hard to do, but we have to experiment.”

The recent increase in cases of nosocomial infections such as methicillin-resistant Staphylococcus aureus “should be a wake-up call for everybody,” Sen. Clinton said. “A couple of hospitals I'm aware of have changed their infection control policies; they have cut the rate of hospital-borne infections. Everybody should be expected to do that.”

'I'm intrigued by the fact that a lot of states are permitting pharmacists to give vaccines.' SEN. CLINTON

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory. "I don't think there should be a mandate for every American to have health insurance," the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals.

"I think one of our goals should be that every American own their own home, but I'm not going to mandate that. … I feel the same way about health care. If it's affordable and available, then it seems to me it's a matter of choice amongst Americans," he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. "The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to" sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, "and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage."

Instead of mandating that people have health insurance, Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. "I'm not going to force Americans to do it; I don't think that's the role of government," he said. "But if we can bring down costs, as I believe we can. …I'm absolutely convinced more and more people will take advantage of [health insurance]. The panacea isn't all just health care costs, but unless you address health care costs, you're never going to solve the other aspects of the health care crisis."

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. "Right now we pay for every single procedure—the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers."

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits—which would cost the government an estimated $3.5 trillion over 10 years—he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction that employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

"The important thing about the … refundable tax credit for employees is for them to go out and make choices," Sen. McCain said during the forum.

"When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else." And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year—far higher than the amount of the proposed family tax credit—Sen. McCain said the credit still would be beneficial.

"One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan," he said. "Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it]."

Sen. McCain admitted that the tax credit plan "is not a perfect solution, and if not for the price tag involved, I'd make it even higher. But according to the Congressional Budget Office, by shifting the employee tax aspect of it, you save $3.5 trillion over a 10-year period, and I think that would have some beneficial effect at reducing the overall health care cost burden that we're laying on future generations." The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the "cherry-picking" that some health plans do to make certain they insure mostly healthy people. Outlawing cherry-picking "would be mandating what the free enterprise system does and that would be obviously something that I would not approve of." Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents. "I would rather go that route than mandate that health insurance companies under any condition would have to accept a certain level of patients. … One reason is that we have seen in the past that [insurance companies] have a great ability to game the system."

Sen. McCain also said he hoped the tax credit plan would encourage more people to open health savings accounts (HSAs). "I think they are a good idea; I don't think they've been publicized nearly as much as they should be," he said. "Rightly or wrongly, HSAs are viewed by most Americans as something for rich people. But if you can only use that refundable tax credit for purchasing health insurance or HSAs, I think you may see a stimulus in that; at least, I believe that's a strong possibility."

On another front, the senator said in an interview that he favors reforms to the malpractice system. "I would like to see that any medical provider or doctor who stayed within medical guidelines would then not be sued. Right now, it's a lottery for trial lawyers." He is in favor of damage caps, "but more importantly, I've opposed punitive damages. … Punitive damages are something that I have not supported in anything."

Sen. McCain also noted that although he is against abortion, "after a lot of agonizing thought and consultation, I believe in stem cell research. I think stem cell research holds great promise in addressing some of these terrible afflictions that face our nation and the world, such as Alzheimer's and Parkinson's."

A large portion of the 47 million Americans who are without health insurance choose not to sign up. SEN. MCCAIN

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory. "I don't think there should be a mandate for every American to have health insurance," the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals.

"I think one of our goals should be that every American own their own home, but I'm not going to mandate that. … I feel the same way about health care. If it's affordable and available, then it seems to me it's a matter of choice amongst Americans," he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. "The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to" sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, "and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage."

Instead of mandating that people have health insurance, Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. "I'm not going to force Americans to do it; I don't think that's the role of government," he said. "But if we can bring down costs, as I believe we can. …I'm absolutely convinced more and more people will take advantage of [health insurance]. The panacea isn't all just health care costs, but unless you address health care costs, you're never going to solve the other aspects of the health care crisis."

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. "Right now we pay for every single procedure—the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers."

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits—which would cost the government an estimated $3.5 trillion over 10 years—he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction that employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

"The important thing about the … refundable tax credit for employees is for them to go out and make choices," Sen. McCain said during the forum.

"When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else." And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year—far higher than the amount of the proposed family tax credit—Sen. McCain said the credit still would be beneficial.

"One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan," he said. "Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it]."

Sen. McCain admitted that the tax credit plan "is not a perfect solution, and if not for the price tag involved, I'd make it even higher. But according to the Congressional Budget Office, by shifting the employee tax aspect of it, you save $3.5 trillion over a 10-year period, and I think that would have some beneficial effect at reducing the overall health care cost burden that we're laying on future generations." The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the "cherry-picking" that some health plans do to make certain they insure mostly healthy people. Outlawing cherry-picking "would be mandating what the free enterprise system does and that would be obviously something that I would not approve of." Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents. "I would rather go that route than mandate that health insurance companies under any condition would have to accept a certain level of patients. … One reason is that we have seen in the past that [insurance companies] have a great ability to game the system."

Sen. McCain also said he hoped the tax credit plan would encourage more people to open health savings accounts (HSAs). "I think they are a good idea; I don't think they've been publicized nearly as much as they should be," he said. "Rightly or wrongly, HSAs are viewed by most Americans as something for rich people. But if you can only use that refundable tax credit for purchasing health insurance or HSAs, I think you may see a stimulus in that; at least, I believe that's a strong possibility."

On another front, the senator said in an interview that he favors reforms to the malpractice system. "I would like to see that any medical provider or doctor who stayed within medical guidelines would then not be sued. Right now, it's a lottery for trial lawyers." He is in favor of damage caps, "but more importantly, I've opposed punitive damages. … Punitive damages are something that I have not supported in anything."

Sen. McCain also noted that although he is against abortion, "after a lot of agonizing thought and consultation, I believe in stem cell research. I think stem cell research holds great promise in addressing some of these terrible afflictions that face our nation and the world, such as Alzheimer's and Parkinson's."

A large portion of the 47 million Americans who are without health insurance choose not to sign up. SEN. MCCAIN

For Sen. John McCain (R-Ariz.), having health insurance is desirable but not mandatory. "I don't think there should be a mandate for every American to have health insurance," the Republican presidential hopeful said at a forum on health care policy sponsored by Families USA and the Federation of American Hospitals.

"I think one of our goals should be that every American own their own home, but I'm not going to mandate that. … I feel the same way about health care. If it's affordable and available, then it seems to me it's a matter of choice amongst Americans," he said.

As Sen. McCain sees it, health insurance is something many people decide they don't want. "The 47 million Americans that are without health insurance today, a very large portion of them are healthy young Americans who simply choose not to" sign up for it, he said at the forum, which was underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. He added, however, that some people with chronic illnesses and other preexisting conditions do have problems accessing insurance, "and we have to make special provisions for them, including additional trust funds for Medicaid payments [for people] who need this kind of coverage."

Instead of mandating that people have health insurance, Sen. McCain, who is serving his fourth term in Congress, said his priority as president would be to rein in health care costs. "I'm not going to force Americans to do it; I don't think that's the role of government," he said. "But if we can bring down costs, as I believe we can. …I'm absolutely convinced more and more people will take advantage of [health insurance]. The panacea isn't all just health care costs, but unless you address health care costs, you're never going to solve the other aspects of the health care crisis."

One way to control costs at the federal level is to not pay for medical errors involving Medicare patients, Sen. McCain said in an interview after the forum. "Right now we pay for every single procedure—the MRI, the CT scan, the transfusion, whatever it is. [Instead], we should be paying the provider and the doctor a certain set amount of money directly related to overall care and results. That way we remove the incentives now in place for overmedicating, overtaxing, and overindulging in unnecessary procedures. I also think it rewards good performance by the providers."

To expand access to health insurance, Sen. McCain is proposing a refundable tax credit of $2,500 per individual and $5,000 per family to help the uninsured buy health insurance policies. To pay for the tax credits—which would cost the government an estimated $3.5 trillion over 10 years—he proposes abolishing the tax deduction that employees currently take when they pay premiums on their employer-sponsored health plans. He would, however, leave intact the deduction that employers currently take on their portion of the premiums as an incentive for employers to continue offering coverage.

"The important thing about the … refundable tax credit for employees is for them to go out and make choices," Sen. McCain said during the forum.

"When it's their money and their decision, I think they make much wiser decisions than when it's provided by somebody else." And because the tax credit is refundable, low-income Americans who currently pay no taxes will receive a check for the amount of the credit, he noted.

When a reporter pointed out that the average cost of a family health insurance policy is more than $12,000 per year—far higher than the amount of the proposed family tax credit—Sen. McCain said the credit still would be beneficial.

"One thing it does is if someone has a gold-plated health insurance policy, they'll start to pay taxes [on those premiums] and it may make them make different decisions about the extent and coverage of their health insurance plan," he said. "Another thing it does that I think is very important is that for low-income people who have no health insurance today, at least now they've got $2,500, or $5,000 in the case of a family, to go out and at least start beginning to have [it]."

Sen. McCain admitted that the tax credit plan "is not a perfect solution, and if not for the price tag involved, I'd make it even higher. But according to the Congressional Budget Office, by shifting the employee tax aspect of it, you save $3.5 trillion over a 10-year period, and I think that would have some beneficial effect at reducing the overall health care cost burden that we're laying on future generations." The senator said he did not have an estimate of how many uninsured people would be able to buy health insurance coverage because of the tax credit.

Sen. McCain said he does not support outlawing the "cherry-picking" that some health plans do to make certain they insure mostly healthy people. Outlawing cherry-picking "would be mandating what the free enterprise system does and that would be obviously something that I would not approve of." Instead, he favored broadening the high-risk pools that states use to provide coverage for some of their uninsured residents. "I would rather go that route than mandate that health insurance companies under any condition would have to accept a certain level of patients. … One reason is that we have seen in the past that [insurance companies] have a great ability to game the system."

Sen. McCain also said he hoped the tax credit plan would encourage more people to open health savings accounts (HSAs). "I think they are a good idea; I don't think they've been publicized nearly as much as they should be," he said. "Rightly or wrongly, HSAs are viewed by most Americans as something for rich people. But if you can only use that refundable tax credit for purchasing health insurance or HSAs, I think you may see a stimulus in that; at least, I believe that's a strong possibility."

On another front, the senator said in an interview that he favors reforms to the malpractice system. "I would like to see that any medical provider or doctor who stayed within medical guidelines would then not be sued. Right now, it's a lottery for trial lawyers." He is in favor of damage caps, "but more importantly, I've opposed punitive damages. … Punitive damages are something that I have not supported in anything."

Sen. McCain also noted that although he is against abortion, "after a lot of agonizing thought and consultation, I believe in stem cell research. I think stem cell research holds great promise in addressing some of these terrible afflictions that face our nation and the world, such as Alzheimer's and Parkinson's."

A large portion of the 47 million Americans who are without health insurance choose not to sign up. SEN. MCCAIN