Mary Ellen Schneider

Fall-Related Injury Legislation

President Bush recently signed legislation to prevent falls among the elderly. The Safety of Seniors Act of 2008 (H.R. 3701) directs the Secretary of Health and Human Services to conduct and support research to improve the identification of older adults who may be at risk for falling, develop and evaluate effective fall prevention interventions, and improve the diagnosis and treatment of fall victims. The legislation, introduced by Rep. Frank Pallone Jr. (D-N.J.), also calls on HHS to report to Congress on the potential for reducing falls and the most effective strategies for reducing the health care costs associated with falls. The legislation also includes a national public education campaign aimed at older adults and health care providers that would focus on reducing falls and preventing repeat falls. “Effective demonstration tests, comprehensive public information and education campaigns can help reduce and mitigate these avoidable and frequently disabling injuries,” Rep. Pallone said in a statement. “This new law launches a comprehensive preventative care program to reduce the number and severity of falls to the elderly.”

Feds Develop Lupus Campaign

The federal government is developing a National Lupus Awareness campaign to increase the public's understanding of lupus symptoms, its health effects, and who is at risk for the condition. The marketing campaign also aims to raise awareness that lupus disproportionately affects young women of color. The project is being spearheaded by the Office of Women's Health, part of the Department of Health and Human Services, with support from the Advertising Council. Officials in the Office of Women's Health are also seeking lupus and women's health organizations to partner with on the project. The campaign will target the low public recognition of lupus that was documented by the Lupus Foundation of America in a recent survey. The group found that among 1,000 U.S. adults, 39% knew nothing about the disease and 22% had never even heard of it.

Arthritis Creates Exercise Barrier

Comorbid arthritis is a significant barrier to exercise for people with diabetes, the Centers for Disease Control and Prevention reported in the Morbidity and Mortality Weekly Report. The agency's national survey found that 30% of people who have both disorders are physically inactive, compared with 21% of those who have only diabetes and 17% of those who have only arthritis. “These findings suggest that more needs to be done to help people with diabetes and arthritis get physically active to improve their health,” Dr. Chad Helmick, coauthor of the study and a CDC medical epidemiologist, said in a statement. “Engaging in regular physical activity and maintaining a healthy weight can help alleviate the pain and disability that often accompany arthritis.” The CDC based its report on 2005 and 2007 data from the Behavioral Risk Factor Surveillance System. This state-based random telephone survey has been tracking health conditions and risk behaviors in the United States yearly since 1984. The data from 2005 and 2007 were combined to increase statistical power.

FDA Pushes for Adverse Event Reports

The Food and Drug Administration is working with a medical software firm to get more physicians to submit adverse event reports to the agency. Doctors who use Epocrates products received a message on their personal digital assistant explaining how adverse event reporting works. “Physicians are on the frontline when it comes to patient care, and working with Epocrates helps us remind them of safety and error reporting directly at the point of patient contact,” said Dr. Norman Marks, medical director of the FDA's MedWatch program. “We want physicians to understand that by taking a few minutes to submit a report, that action may be the necessary first step that triggers an evaluation and action by the FDA.”

Low Postmarket Compliance

The FDA has issued its annual summary report on whether pharmaceutical and biologic manufacturers are meeting their commitments to conduct postmarketing studies. According to the agency, 76% of drug makers and 81% of biologic makers had met their commitment as of Sept. 30, 2007. There were 136 drug makers and 54 biologic manufacturers with open postmarketing commitments as of that date. A closer look shows that only 12% of drug studies were completed or terminated with a final report submitted to the FDA that year. In all, 20% of biologics met that goal. Manufacturers must report annually on the status of safety, efficacy, pharmacology, and nonclinical toxicology studies required by the FDA, or report that they have committed to conduct at the time of approval or after approval.

Fall-Related Injury Legislation

President Bush recently signed legislation to prevent falls among the elderly. The Safety of Seniors Act of 2008 (H.R. 3701) directs the Secretary of Health and Human Services to conduct and support research to improve the identification of older adults who may be at risk for falling, develop and evaluate effective fall prevention interventions, and improve the diagnosis and treatment of fall victims. The legislation, introduced by Rep. Frank Pallone Jr. (D-N.J.), also calls on HHS to report to Congress on the potential for reducing falls and the most effective strategies for reducing the health care costs associated with falls. The legislation also includes a national public education campaign aimed at older adults and health care providers that would focus on reducing falls and preventing repeat falls. “Effective demonstration tests, comprehensive public information and education campaigns can help reduce and mitigate these avoidable and frequently disabling injuries,” Rep. Pallone said in a statement. “This new law launches a comprehensive preventative care program to reduce the number and severity of falls to the elderly.”

Feds Develop Lupus Campaign

The federal government is developing a National Lupus Awareness campaign to increase the public's understanding of lupus symptoms, its health effects, and who is at risk for the condition. The marketing campaign also aims to raise awareness that lupus disproportionately affects young women of color. The project is being spearheaded by the Office of Women's Health, part of the Department of Health and Human Services, with support from the Advertising Council. Officials in the Office of Women's Health are also seeking lupus and women's health organizations to partner with on the project. The campaign will target the low public recognition of lupus that was documented by the Lupus Foundation of America in a recent survey. The group found that among 1,000 U.S. adults, 39% knew nothing about the disease and 22% had never even heard of it.

Arthritis Creates Exercise Barrier

Comorbid arthritis is a significant barrier to exercise for people with diabetes, the Centers for Disease Control and Prevention reported in the Morbidity and Mortality Weekly Report. The agency's national survey found that 30% of people who have both disorders are physically inactive, compared with 21% of those who have only diabetes and 17% of those who have only arthritis. “These findings suggest that more needs to be done to help people with diabetes and arthritis get physically active to improve their health,” Dr. Chad Helmick, coauthor of the study and a CDC medical epidemiologist, said in a statement. “Engaging in regular physical activity and maintaining a healthy weight can help alleviate the pain and disability that often accompany arthritis.” The CDC based its report on 2005 and 2007 data from the Behavioral Risk Factor Surveillance System. This state-based random telephone survey has been tracking health conditions and risk behaviors in the United States yearly since 1984. The data from 2005 and 2007 were combined to increase statistical power.

FDA Pushes for Adverse Event Reports

The Food and Drug Administration is working with a medical software firm to get more physicians to submit adverse event reports to the agency. Doctors who use Epocrates products received a message on their personal digital assistant explaining how adverse event reporting works. “Physicians are on the frontline when it comes to patient care, and working with Epocrates helps us remind them of safety and error reporting directly at the point of patient contact,” said Dr. Norman Marks, medical director of the FDA's MedWatch program. “We want physicians to understand that by taking a few minutes to submit a report, that action may be the necessary first step that triggers an evaluation and action by the FDA.”

Low Postmarket Compliance

The FDA has issued its annual summary report on whether pharmaceutical and biologic manufacturers are meeting their commitments to conduct postmarketing studies. According to the agency, 76% of drug makers and 81% of biologic makers had met their commitment as of Sept. 30, 2007. There were 136 drug makers and 54 biologic manufacturers with open postmarketing commitments as of that date. A closer look shows that only 12% of drug studies were completed or terminated with a final report submitted to the FDA that year. In all, 20% of biologics met that goal. Manufacturers must report annually on the status of safety, efficacy, pharmacology, and nonclinical toxicology studies required by the FDA, or report that they have committed to conduct at the time of approval or after approval.

Fall-Related Injury Legislation

President Bush recently signed legislation to prevent falls among the elderly. The Safety of Seniors Act of 2008 (H.R. 3701) directs the Secretary of Health and Human Services to conduct and support research to improve the identification of older adults who may be at risk for falling, develop and evaluate effective fall prevention interventions, and improve the diagnosis and treatment of fall victims. The legislation, introduced by Rep. Frank Pallone Jr. (D-N.J.), also calls on HHS to report to Congress on the potential for reducing falls and the most effective strategies for reducing the health care costs associated with falls. The legislation also includes a national public education campaign aimed at older adults and health care providers that would focus on reducing falls and preventing repeat falls. “Effective demonstration tests, comprehensive public information and education campaigns can help reduce and mitigate these avoidable and frequently disabling injuries,” Rep. Pallone said in a statement. “This new law launches a comprehensive preventative care program to reduce the number and severity of falls to the elderly.”

Feds Develop Lupus Campaign

The federal government is developing a National Lupus Awareness campaign to increase the public's understanding of lupus symptoms, its health effects, and who is at risk for the condition. The marketing campaign also aims to raise awareness that lupus disproportionately affects young women of color. The project is being spearheaded by the Office of Women's Health, part of the Department of Health and Human Services, with support from the Advertising Council. Officials in the Office of Women's Health are also seeking lupus and women's health organizations to partner with on the project. The campaign will target the low public recognition of lupus that was documented by the Lupus Foundation of America in a recent survey. The group found that among 1,000 U.S. adults, 39% knew nothing about the disease and 22% had never even heard of it.

Arthritis Creates Exercise Barrier

Comorbid arthritis is a significant barrier to exercise for people with diabetes, the Centers for Disease Control and Prevention reported in the Morbidity and Mortality Weekly Report. The agency's national survey found that 30% of people who have both disorders are physically inactive, compared with 21% of those who have only diabetes and 17% of those who have only arthritis. “These findings suggest that more needs to be done to help people with diabetes and arthritis get physically active to improve their health,” Dr. Chad Helmick, coauthor of the study and a CDC medical epidemiologist, said in a statement. “Engaging in regular physical activity and maintaining a healthy weight can help alleviate the pain and disability that often accompany arthritis.” The CDC based its report on 2005 and 2007 data from the Behavioral Risk Factor Surveillance System. This state-based random telephone survey has been tracking health conditions and risk behaviors in the United States yearly since 1984. The data from 2005 and 2007 were combined to increase statistical power.

FDA Pushes for Adverse Event Reports

The Food and Drug Administration is working with a medical software firm to get more physicians to submit adverse event reports to the agency. Doctors who use Epocrates products received a message on their personal digital assistant explaining how adverse event reporting works. “Physicians are on the frontline when it comes to patient care, and working with Epocrates helps us remind them of safety and error reporting directly at the point of patient contact,” said Dr. Norman Marks, medical director of the FDA's MedWatch program. “We want physicians to understand that by taking a few minutes to submit a report, that action may be the necessary first step that triggers an evaluation and action by the FDA.”

Low Postmarket Compliance

The FDA has issued its annual summary report on whether pharmaceutical and biologic manufacturers are meeting their commitments to conduct postmarketing studies. According to the agency, 76% of drug makers and 81% of biologic makers had met their commitment as of Sept. 30, 2007. There were 136 drug makers and 54 biologic manufacturers with open postmarketing commitments as of that date. A closer look shows that only 12% of drug studies were completed or terminated with a final report submitted to the FDA that year. In all, 20% of biologics met that goal. Manufacturers must report annually on the status of safety, efficacy, pharmacology, and nonclinical toxicology studies required by the FDA, or report that they have committed to conduct at the time of approval or after approval.

The presidential candidates aren't the only ones with proposals to reform the American health care system.

While the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan (SCHIP) to cover all adults and children below 150% of the federal poverty level. And the plan would include both individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians, investing in better health information technology, allowing Medicare to negotiate drug prices, and improving public health, according to the Commonwealth Fund.

“This approach builds on group insurance coverage and the national reach of Medicare and at the same time addresses the high administrative and premium costs for individuals and small groups,” Karen Davis, Commonwealth Fund president, said in a statement.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans. Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance.

The plan also calls for moving away from a payment system that rewards physicians and hospitals for the volume of services they provide and instead paying for evidence-based care and prevention. The current model rewards inefficiency and pays better when patients are sicker, Dr. Denis Cortese, chair of the Healthcare Leadership Council and president and chief executive officer of the Mayo Clinic, said during a press briefing to release the plan.

“We really are suggesting we turn that upside down,” Dr. Cortese said.

The presidential candidates aren't the only ones with proposals to reform the American health care system.

While the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan (SCHIP) to cover all adults and children below 150% of the federal poverty level. And the plan would include both individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians, investing in better health information technology, allowing Medicare to negotiate drug prices, and improving public health, according to the Commonwealth Fund.

“This approach builds on group insurance coverage and the national reach of Medicare and at the same time addresses the high administrative and premium costs for individuals and small groups,” Karen Davis, Commonwealth Fund president, said in a statement.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans. Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance.

The plan also calls for moving away from a payment system that rewards physicians and hospitals for the volume of services they provide and instead paying for evidence-based care and prevention. The current model rewards inefficiency and pays better when patients are sicker, Dr. Denis Cortese, chair of the Healthcare Leadership Council and president and chief executive officer of the Mayo Clinic, said during a press briefing to release the plan.

“We really are suggesting we turn that upside down,” Dr. Cortese said.

The presidential candidates aren't the only ones with proposals to reform the American health care system.

While the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan (SCHIP) to cover all adults and children below 150% of the federal poverty level. And the plan would include both individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians, investing in better health information technology, allowing Medicare to negotiate drug prices, and improving public health, according to the Commonwealth Fund.

“This approach builds on group insurance coverage and the national reach of Medicare and at the same time addresses the high administrative and premium costs for individuals and small groups,” Karen Davis, Commonwealth Fund president, said in a statement.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans. Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance.

The plan also calls for moving away from a payment system that rewards physicians and hospitals for the volume of services they provide and instead paying for evidence-based care and prevention. The current model rewards inefficiency and pays better when patients are sicker, Dr. Denis Cortese, chair of the Healthcare Leadership Council and president and chief executive officer of the Mayo Clinic, said during a press briefing to release the plan.

“We really are suggesting we turn that upside down,” Dr. Cortese said.

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund.

The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research.

The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election

Sen. John McCain's health plan would eliminate the tax exclusion that allows employees to avoid paying income tax on the value of benefits. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund.

The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research.

The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election

Sen. John McCain's health plan would eliminate the tax exclusion that allows employees to avoid paying income tax on the value of benefits. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund.

The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research.

The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election

Sen. John McCain's health plan would eliminate the tax exclusion that allows employees to avoid paying income tax on the value of benefits. John McCain 2008/

State figures are at www.familiesusa.org

In 2006, more than seven working age people in Texas died each day due to a lack of health insurance, according to the consumer group Families USA.

Families USA released state-by-state estimates of deaths attributed to a lack of health insurance for individuals ages 25–64 years. The report builds on the work of the Institute of Medicine, which in 2002 released a report that found that approximately 18,000 individuals ages 25–64 years died in 2000 because they were uninsured. A more recent study from the Urban Institute found that approximately 22,000 people in that age bracket died in 2006 because they didn't have health insurance.

“Our inadequate system of health coverage condemns a great number of people to an early death simply because they don't have the same access to health care as their insured neighbors,” Ron Pollack, executive director of Families USA, said during a teleconference. “A lack of health coverage is a matter of life and death for many.”

In general, the uninsured are less likely to have a usual source of care outside of the emergency department, they often go without screenings and preventive care, and they frequently forego needed medical treatment, Mr. Pollack said.

In Utah, where 19% of the 1.2 million working age people in the state were uninsured in 2006, on average 3 people died each week due to a lack of health insurance coverage. Between 2000 and 2006, more than 800 people died due to lack of health insurance, the group estimated.

In Massachusetts, about 12% of the 3.4 million people aged 25–64 years were uninsured in 2006. Families USA estimates that more than 6 working age individuals in the state died each week in 2006 due to a lack of insurance coverage. Between 2000 and 2006, more than 2,000 working age adults died because they didn't have insurance coverage, the group estimated.

The Families USA estimates are based on 2000–2005 state mortality and population data from the National Center for Health Statistics and the U.S. Census Bureau Current Population Survey data from 2000 to 2006. The group released 50 state specific reports but does not make state-to-state comparisons. The differing population size, mortality rates, and uninsured rates make it difficult to compare states, according to Families USA.

State figures are at www.familiesusa.org

In 2006, more than seven working age people in Texas died each day due to a lack of health insurance, according to the consumer group Families USA.

Families USA released state-by-state estimates of deaths attributed to a lack of health insurance for individuals ages 25–64 years. The report builds on the work of the Institute of Medicine, which in 2002 released a report that found that approximately 18,000 individuals ages 25–64 years died in 2000 because they were uninsured. A more recent study from the Urban Institute found that approximately 22,000 people in that age bracket died in 2006 because they didn't have health insurance.

“Our inadequate system of health coverage condemns a great number of people to an early death simply because they don't have the same access to health care as their insured neighbors,” Ron Pollack, executive director of Families USA, said during a teleconference. “A lack of health coverage is a matter of life and death for many.”

In general, the uninsured are less likely to have a usual source of care outside of the emergency department, they often go without screenings and preventive care, and they frequently forego needed medical treatment, Mr. Pollack said.

In Utah, where 19% of the 1.2 million working age people in the state were uninsured in 2006, on average 3 people died each week due to a lack of health insurance coverage. Between 2000 and 2006, more than 800 people died due to lack of health insurance, the group estimated.

In Massachusetts, about 12% of the 3.4 million people aged 25–64 years were uninsured in 2006. Families USA estimates that more than 6 working age individuals in the state died each week in 2006 due to a lack of insurance coverage. Between 2000 and 2006, more than 2,000 working age adults died because they didn't have insurance coverage, the group estimated.

The Families USA estimates are based on 2000–2005 state mortality and population data from the National Center for Health Statistics and the U.S. Census Bureau Current Population Survey data from 2000 to 2006. The group released 50 state specific reports but does not make state-to-state comparisons. The differing population size, mortality rates, and uninsured rates make it difficult to compare states, according to Families USA.

State figures are at www.familiesusa.org

In 2006, more than seven working age people in Texas died each day due to a lack of health insurance, according to the consumer group Families USA.

Families USA released state-by-state estimates of deaths attributed to a lack of health insurance for individuals ages 25–64 years. The report builds on the work of the Institute of Medicine, which in 2002 released a report that found that approximately 18,000 individuals ages 25–64 years died in 2000 because they were uninsured. A more recent study from the Urban Institute found that approximately 22,000 people in that age bracket died in 2006 because they didn't have health insurance.

“Our inadequate system of health coverage condemns a great number of people to an early death simply because they don't have the same access to health care as their insured neighbors,” Ron Pollack, executive director of Families USA, said during a teleconference. “A lack of health coverage is a matter of life and death for many.”

In general, the uninsured are less likely to have a usual source of care outside of the emergency department, they often go without screenings and preventive care, and they frequently forego needed medical treatment, Mr. Pollack said.

In Utah, where 19% of the 1.2 million working age people in the state were uninsured in 2006, on average 3 people died each week due to a lack of health insurance coverage. Between 2000 and 2006, more than 800 people died due to lack of health insurance, the group estimated.

In Massachusetts, about 12% of the 3.4 million people aged 25–64 years were uninsured in 2006. Families USA estimates that more than 6 working age individuals in the state died each week in 2006 due to a lack of insurance coverage. Between 2000 and 2006, more than 2,000 working age adults died because they didn't have insurance coverage, the group estimated.

The Families USA estimates are based on 2000–2005 state mortality and population data from the National Center for Health Statistics and the U.S. Census Bureau Current Population Survey data from 2000 to 2006. The group released 50 state specific reports but does not make state-to-state comparisons. The differing population size, mortality rates, and uninsured rates make it difficult to compare states, according to Families USA.

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines. “Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. “We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

Sen. McCain proposes changing the tax structure to pay for health coverage. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines. “Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. “We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

Sen. McCain proposes changing the tax structure to pay for health coverage. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines. “Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. “We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

Sen. McCain proposes changing the tax structure to pay for health coverage. John McCain 2008/

The presidential candidates aren't the only ones with proposals to reform the American health care system.

Although the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large-employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan (SCHIP) to cover all adults and children below 150% of the federal poverty level. Moreover, the plan would include both individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians, investing in better health information technology, allowing Medicare to negotiate drug prices, and improving public health, according to the Commonwealth Fund.

“This approach builds on group insurance coverage and the national reach of Medicare and at the same time addresses the high administrative and premium costs for individuals and small groups,” Karen Davis, Commonwealth Fund president, said in a statement.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans.

Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance.

The plan also calls for moving away from a payment system that rewards physicians and hospitals for the volume of services they provide and instead paying for evidence-based care and prevention. The current model rewards inefficiency and pays better when patients are sicker, Dr. Denis Cortese, chair of the Healthcare Leadership Council and president and chief executive officer of the Mayo Clinic, said during a press briefing to release the plan.

“We really are suggesting we turn that upside down,” he said.

The presidential candidates aren't the only ones with proposals to reform the American health care system.

Although the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large-employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan (SCHIP) to cover all adults and children below 150% of the federal poverty level. Moreover, the plan would include both individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians, investing in better health information technology, allowing Medicare to negotiate drug prices, and improving public health, according to the Commonwealth Fund.

“This approach builds on group insurance coverage and the national reach of Medicare and at the same time addresses the high administrative and premium costs for individuals and small groups,” Karen Davis, Commonwealth Fund president, said in a statement.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans.

Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance.

The plan also calls for moving away from a payment system that rewards physicians and hospitals for the volume of services they provide and instead paying for evidence-based care and prevention. The current model rewards inefficiency and pays better when patients are sicker, Dr. Denis Cortese, chair of the Healthcare Leadership Council and president and chief executive officer of the Mayo Clinic, said during a press briefing to release the plan.

“We really are suggesting we turn that upside down,” he said.

The presidential candidates aren't the only ones with proposals to reform the American health care system.

Although the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large-employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan (SCHIP) to cover all adults and children below 150% of the federal poverty level. Moreover, the plan would include both individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians, investing in better health information technology, allowing Medicare to negotiate drug prices, and improving public health, according to the Commonwealth Fund.

“This approach builds on group insurance coverage and the national reach of Medicare and at the same time addresses the high administrative and premium costs for individuals and small groups,” Karen Davis, Commonwealth Fund president, said in a statement.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans.

Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance.

The plan also calls for moving away from a payment system that rewards physicians and hospitals for the volume of services they provide and instead paying for evidence-based care and prevention. The current model rewards inefficiency and pays better when patients are sicker, Dr. Denis Cortese, chair of the Healthcare Leadership Council and president and chief executive officer of the Mayo Clinic, said during a press briefing to release the plan.

“We really are suggesting we turn that upside down,” he said.

Patients will soon be able to undergo genetic testing without fear of discrimination from either their health insurers or their employers, thanks to a new law signed by President Bush.

The Genetic Information Nondiscrimination Act (H.R. 493), which passed both houses of Congress by wide margins, prohibits health insurers from using genetic information in determining eligibility or setting premiums and forbids employers from using that information for decisions about hiring, firing, job assignments, or promotions. The law also prohibits health insurers and employers from requesting or requiring that individuals take a genetic test. The health insurance provisions in the law will go into effect in 12 months, and the employment provisions will take effect in 18 months.

“Genetic testing holds great promise for improving public health, and patients must be able to trust that their genetic information will be protected from inappropriate and discriminatory uses,” Dr. Edward Langston, board chair of the American Medical Association, said in a statement. “This new law will allow patients to take advantage of scientific advances in genetics, such as screenings and therapies, without worrying that their personal health information could be used against them by insurers or employers.”

“No one should have their health insurance or employment removed from them based on the potential for having a disease,” said Dr. James King, president of the American Academy of Family Physicians. Although there is not yet a lot of genetic testing being done, the laws gives physicians and patients a greater level of comfort in ordering tests when early treatment or prevention strategies could benefit the patient, he said.

“Today, the genetic revolution in health care can truly begin,” Dr. Renee R. Jenkins, president of the American Academy of Pediatrics, said in a statement. “For the first time since the development of genetic tests, parents can rest assured that they and their children will not lose their health insurance or their jobs just because their genetic makeup says they are at risk for a specific disease.”

Supporters of the law are hailing it as the first civil rights legislation of the new millennium. In practice, experts say that it will mean that patients who might have been hesitant to undergo testing for fear of discrimination may be more willing. Some patients who would be good candidates for genetic testing have been refusing the tests, or in some cases taking them under an assumed name, said Sharon Terry, president of the Coalition for Genetic Fairness and CEO of the Genetic Alliance.

The frequency of genetic discrimination has been difficult to document, but it's clear that fear of discrimination has been a barrier to genetic services for some patients, said Dr. Matthew Taylor, director of adult clinical genetics at the University of Colorado in Denver. For example, last year the Genetics and Public Policy Center at Johns Hopkins University, Baltimore, conducted a survey of 1,199 U.S. adults on genetic testing and discrimination. The researchers found that 92% of respondents expressed concern that the results of a genetic test for disease risk could be used against them in some way.

One of the biggest impacts of the law may be its potential to alleviate concerns about genetic discrimination among both patients and physicians, Dr. Taylor said.

Another area where the law is likely to have a significant impact is in research. Many informed consent forms for clinical trials include statements warning participants that they could be discriminated against on the basis of their genetic information, according to Ms. Terry. The Coalition for Genetic Fairness plans to mount an educational campaign to make patients and physicians aware of the new protections in the law in the hopes of increasing participation in research, she said.

The new federal law is essential to help to “close the gaps in protection” among the various state laws, according to Naomi Senkeeto, a health policy analyst for the American College of Physicians. The new law is similar to policy positions outlined in an ACP monograph issued earlier this year. In fact, the law includes all of the provisions that the ACP monograph recommended. The law also adds a specific prohibition against issuers of Medigap policies using genetic information to adjust price or condition eligibility.

The law was a long time coming, according to supporters. Legislation on genetic nondiscrimination was first introduced in 1995. The bill has had broad support in Congress for many years but couldn't get to the House floor under the Republican leadership, according to Susannah Baruch, associate director of the Genetics and Public Policy Center at Johns Hopkins University. The other change that propelled the legislation forward was the explosion in the number of genetic tests available, she said.

About 1,200 genetic tests can be used to identify thousands of health conditions, according to the Coalition for Genetic Fairness. Only about 100 genetic tests were available a decade ago.

Over time, the legislation has garnered support from a broad coalition of groups, including the health insurance industry. “With this landmark bipartisan legislation, Congress and the President have taken strong action to prohibit discrimination based on a person's genetic makeup and to protect patients' privacy as they pursue genetic evaluations,” Karen Ignagni, president of America's Health Insurance Plans, said in a statement. “This legislation also ensures that patients can continue to benefit from health plans' innovative early detection and care coordination programs that improve the safety and quality of care.”

But more work is needed, Ms. Terry said. “This is a first-step bill for sure.”

Patients will soon be able to undergo genetic testing without fear of discrimination from either their health insurers or their employers, thanks to a new law signed by President Bush.

The Genetic Information Nondiscrimination Act (H.R. 493), which passed both houses of Congress by wide margins, prohibits health insurers from using genetic information in determining eligibility or setting premiums and forbids employers from using that information for decisions about hiring, firing, job assignments, or promotions. The law also prohibits health insurers and employers from requesting or requiring that individuals take a genetic test. The health insurance provisions in the law will go into effect in 12 months, and the employment provisions will take effect in 18 months.

“Genetic testing holds great promise for improving public health, and patients must be able to trust that their genetic information will be protected from inappropriate and discriminatory uses,” Dr. Edward Langston, board chair of the American Medical Association, said in a statement. “This new law will allow patients to take advantage of scientific advances in genetics, such as screenings and therapies, without worrying that their personal health information could be used against them by insurers or employers.”

“No one should have their health insurance or employment removed from them based on the potential for having a disease,” said Dr. James King, president of the American Academy of Family Physicians. Although there is not yet a lot of genetic testing being done, the laws gives physicians and patients a greater level of comfort in ordering tests when early treatment or prevention strategies could benefit the patient, he said.

“Today, the genetic revolution in health care can truly begin,” Dr. Renee R. Jenkins, president of the American Academy of Pediatrics, said in a statement. “For the first time since the development of genetic tests, parents can rest assured that they and their children will not lose their health insurance or their jobs just because their genetic makeup says they are at risk for a specific disease.”

Supporters of the law are hailing it as the first civil rights legislation of the new millennium. In practice, experts say that it will mean that patients who might have been hesitant to undergo testing for fear of discrimination may be more willing. Some patients who would be good candidates for genetic testing have been refusing the tests, or in some cases taking them under an assumed name, said Sharon Terry, president of the Coalition for Genetic Fairness and CEO of the Genetic Alliance.

The frequency of genetic discrimination has been difficult to document, but it's clear that fear of discrimination has been a barrier to genetic services for some patients, said Dr. Matthew Taylor, director of adult clinical genetics at the University of Colorado in Denver. For example, last year the Genetics and Public Policy Center at Johns Hopkins University, Baltimore, conducted a survey of 1,199 U.S. adults on genetic testing and discrimination. The researchers found that 92% of respondents expressed concern that the results of a genetic test for disease risk could be used against them in some way.

One of the biggest impacts of the law may be its potential to alleviate concerns about genetic discrimination among both patients and physicians, Dr. Taylor said.

Another area where the law is likely to have a significant impact is in research. Many informed consent forms for clinical trials include statements warning participants that they could be discriminated against on the basis of their genetic information, according to Ms. Terry. The Coalition for Genetic Fairness plans to mount an educational campaign to make patients and physicians aware of the new protections in the law in the hopes of increasing participation in research, she said.

The new federal law is essential to help to “close the gaps in protection” among the various state laws, according to Naomi Senkeeto, a health policy analyst for the American College of Physicians. The new law is similar to policy positions outlined in an ACP monograph issued earlier this year. In fact, the law includes all of the provisions that the ACP monograph recommended. The law also adds a specific prohibition against issuers of Medigap policies using genetic information to adjust price or condition eligibility.

The law was a long time coming, according to supporters. Legislation on genetic nondiscrimination was first introduced in 1995. The bill has had broad support in Congress for many years but couldn't get to the House floor under the Republican leadership, according to Susannah Baruch, associate director of the Genetics and Public Policy Center at Johns Hopkins University. The other change that propelled the legislation forward was the explosion in the number of genetic tests available, she said.

About 1,200 genetic tests can be used to identify thousands of health conditions, according to the Coalition for Genetic Fairness. Only about 100 genetic tests were available a decade ago.

Over time, the legislation has garnered support from a broad coalition of groups, including the health insurance industry. “With this landmark bipartisan legislation, Congress and the President have taken strong action to prohibit discrimination based on a person's genetic makeup and to protect patients' privacy as they pursue genetic evaluations,” Karen Ignagni, president of America's Health Insurance Plans, said in a statement. “This legislation also ensures that patients can continue to benefit from health plans' innovative early detection and care coordination programs that improve the safety and quality of care.”

But more work is needed, Ms. Terry said. “This is a first-step bill for sure.”

Patients will soon be able to undergo genetic testing without fear of discrimination from either their health insurers or their employers, thanks to a new law signed by President Bush.

The Genetic Information Nondiscrimination Act (H.R. 493), which passed both houses of Congress by wide margins, prohibits health insurers from using genetic information in determining eligibility or setting premiums and forbids employers from using that information for decisions about hiring, firing, job assignments, or promotions. The law also prohibits health insurers and employers from requesting or requiring that individuals take a genetic test. The health insurance provisions in the law will go into effect in 12 months, and the employment provisions will take effect in 18 months.

“Genetic testing holds great promise for improving public health, and patients must be able to trust that their genetic information will be protected from inappropriate and discriminatory uses,” Dr. Edward Langston, board chair of the American Medical Association, said in a statement. “This new law will allow patients to take advantage of scientific advances in genetics, such as screenings and therapies, without worrying that their personal health information could be used against them by insurers or employers.”

“No one should have their health insurance or employment removed from them based on the potential for having a disease,” said Dr. James King, president of the American Academy of Family Physicians. Although there is not yet a lot of genetic testing being done, the laws gives physicians and patients a greater level of comfort in ordering tests when early treatment or prevention strategies could benefit the patient, he said.

“Today, the genetic revolution in health care can truly begin,” Dr. Renee R. Jenkins, president of the American Academy of Pediatrics, said in a statement. “For the first time since the development of genetic tests, parents can rest assured that they and their children will not lose their health insurance or their jobs just because their genetic makeup says they are at risk for a specific disease.”

Supporters of the law are hailing it as the first civil rights legislation of the new millennium. In practice, experts say that it will mean that patients who might have been hesitant to undergo testing for fear of discrimination may be more willing. Some patients who would be good candidates for genetic testing have been refusing the tests, or in some cases taking them under an assumed name, said Sharon Terry, president of the Coalition for Genetic Fairness and CEO of the Genetic Alliance.

The frequency of genetic discrimination has been difficult to document, but it's clear that fear of discrimination has been a barrier to genetic services for some patients, said Dr. Matthew Taylor, director of adult clinical genetics at the University of Colorado in Denver. For example, last year the Genetics and Public Policy Center at Johns Hopkins University, Baltimore, conducted a survey of 1,199 U.S. adults on genetic testing and discrimination. The researchers found that 92% of respondents expressed concern that the results of a genetic test for disease risk could be used against them in some way.

One of the biggest impacts of the law may be its potential to alleviate concerns about genetic discrimination among both patients and physicians, Dr. Taylor said.

Another area where the law is likely to have a significant impact is in research. Many informed consent forms for clinical trials include statements warning participants that they could be discriminated against on the basis of their genetic information, according to Ms. Terry. The Coalition for Genetic Fairness plans to mount an educational campaign to make patients and physicians aware of the new protections in the law in the hopes of increasing participation in research, she said.

The new federal law is essential to help to “close the gaps in protection” among the various state laws, according to Naomi Senkeeto, a health policy analyst for the American College of Physicians. The new law is similar to policy positions outlined in an ACP monograph issued earlier this year. In fact, the law includes all of the provisions that the ACP monograph recommended. The law also adds a specific prohibition against issuers of Medigap policies using genetic information to adjust price or condition eligibility.

The law was a long time coming, according to supporters. Legislation on genetic nondiscrimination was first introduced in 1995. The bill has had broad support in Congress for many years but couldn't get to the House floor under the Republican leadership, according to Susannah Baruch, associate director of the Genetics and Public Policy Center at Johns Hopkins University. The other change that propelled the legislation forward was the explosion in the number of genetic tests available, she said.

About 1,200 genetic tests can be used to identify thousands of health conditions, according to the Coalition for Genetic Fairness. Only about 100 genetic tests were available a decade ago.

Over time, the legislation has garnered support from a broad coalition of groups, including the health insurance industry. “With this landmark bipartisan legislation, Congress and the President have taken strong action to prohibit discrimination based on a person's genetic makeup and to protect patients' privacy as they pursue genetic evaluations,” Karen Ignagni, president of America's Health Insurance Plans, said in a statement. “This legislation also ensures that patients can continue to benefit from health plans' innovative early detection and care coordination programs that improve the safety and quality of care.”

But more work is needed, Ms. Terry said. “This is a first-step bill for sure.”

PHILADELPHIA — Physicians should test pregnant women for subclinical hypothyroidism and treat the condition to prevent possible fetal death and developmental abnormalities, according to Dr. Stephanie L. Lee, director of the Endocrine Clinics at Boston Medical Center.

For the first 15 weeks of development, the fetus is dependent on the mother's thyroid hormone. “So if Mom is hypothyroid, then baby is hypothyroid during that critical development period,” Dr. Lee said at Endocrinology in the News sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS.

The risks of fetal loss and impaired development have been borne out in recent studies, she said. For example, a study that looked at the consequences of mild hypothyroidism among pregnant women found that the fetal death rate was four times greater in women with elevated levels of thyroid-stimulating hormone (TSH).

The researchers measured TSH in serum samples taken from women during their second trimester as part of their routine prenatal care. Of 9,403 women with singleton pregnancies, 2.2% (209 women) had TSH levels of 6 mU/L or greater. The rate of fetal death was 3.8% among the women with elevated TSH, compared with 0.9% in women with TSH levels less than 6 mU/L (J. Med. Screen. 2000;7:127–30).

In another study by the same group of researchers, the results of IQ testing in children born to women who had untreated hypothyroidism during pregnancy were compared with those of children of women who had normal serum thyrotropin levels during pregnancy. Among the children of 48 women with untreated thyroid deficiency during pregnancy, the IQ scores were on average 7 points lower than those of the children of 124 women with normal thyroid levels. In addition, among children of mothers with untreated thyroid deficiency, 19% had IQ scores of 85 or less, compared with 5% of the other children (N. Engl. J. Med. 1999;341:549–55).

These are two bits of information that suggest that maternal hypothyroidism is a very serious condition and needs to be treated and monitored, said Dr. Lee, who had no commercial support to disclose.

Dr. Lee recommends TSH testing as soon as pregnancy is confirmed in women with a strong family history of hypothyroidism, who have a goiter on exam, or who were taking thyroid hormone prior to conception. She advises continuing to monitor these patients every 4–5 weeks through the first 20 weeks of gestation. After 20 weeks, the increased demand from the fetus seems to slow or stop, Dr. Lee said.

“Because these pregnant women do not see their [obstetricians] until week 12 or 13, it really is up to the internist to make sure that they know that they have to get the thyroid levels checked,” Dr. Lee said.

The Endocrine Society made similar recommendations in clinical practice guidelines released in 2007. The society advises physicians to measure TSH in women at high risk for thyroid disease.

PHILADELPHIA — Physicians should test pregnant women for subclinical hypothyroidism and treat the condition to prevent possible fetal death and developmental abnormalities, according to Dr. Stephanie L. Lee, director of the Endocrine Clinics at Boston Medical Center.

For the first 15 weeks of development, the fetus is dependent on the mother's thyroid hormone. “So if Mom is hypothyroid, then baby is hypothyroid during that critical development period,” Dr. Lee said at Endocrinology in the News sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS.

The risks of fetal loss and impaired development have been borne out in recent studies, she said. For example, a study that looked at the consequences of mild hypothyroidism among pregnant women found that the fetal death rate was four times greater in women with elevated levels of thyroid-stimulating hormone (TSH).

The researchers measured TSH in serum samples taken from women during their second trimester as part of their routine prenatal care. Of 9,403 women with singleton pregnancies, 2.2% (209 women) had TSH levels of 6 mU/L or greater. The rate of fetal death was 3.8% among the women with elevated TSH, compared with 0.9% in women with TSH levels less than 6 mU/L (J. Med. Screen. 2000;7:127–30).

In another study by the same group of researchers, the results of IQ testing in children born to women who had untreated hypothyroidism during pregnancy were compared with those of children of women who had normal serum thyrotropin levels during pregnancy. Among the children of 48 women with untreated thyroid deficiency during pregnancy, the IQ scores were on average 7 points lower than those of the children of 124 women with normal thyroid levels. In addition, among children of mothers with untreated thyroid deficiency, 19% had IQ scores of 85 or less, compared with 5% of the other children (N. Engl. J. Med. 1999;341:549–55).

These are two bits of information that suggest that maternal hypothyroidism is a very serious condition and needs to be treated and monitored, said Dr. Lee, who had no commercial support to disclose.

Dr. Lee recommends TSH testing as soon as pregnancy is confirmed in women with a strong family history of hypothyroidism, who have a goiter on exam, or who were taking thyroid hormone prior to conception. She advises continuing to monitor these patients every 4–5 weeks through the first 20 weeks of gestation. After 20 weeks, the increased demand from the fetus seems to slow or stop, Dr. Lee said.

“Because these pregnant women do not see their [obstetricians] until week 12 or 13, it really is up to the internist to make sure that they know that they have to get the thyroid levels checked,” Dr. Lee said.

The Endocrine Society made similar recommendations in clinical practice guidelines released in 2007. The society advises physicians to measure TSH in women at high risk for thyroid disease.

PHILADELPHIA — Physicians should test pregnant women for subclinical hypothyroidism and treat the condition to prevent possible fetal death and developmental abnormalities, according to Dr. Stephanie L. Lee, director of the Endocrine Clinics at Boston Medical Center.

For the first 15 weeks of development, the fetus is dependent on the mother's thyroid hormone. “So if Mom is hypothyroid, then baby is hypothyroid during that critical development period,” Dr. Lee said at Endocrinology in the News sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS.

The risks of fetal loss and impaired development have been borne out in recent studies, she said. For example, a study that looked at the consequences of mild hypothyroidism among pregnant women found that the fetal death rate was four times greater in women with elevated levels of thyroid-stimulating hormone (TSH).

The researchers measured TSH in serum samples taken from women during their second trimester as part of their routine prenatal care. Of 9,403 women with singleton pregnancies, 2.2% (209 women) had TSH levels of 6 mU/L or greater. The rate of fetal death was 3.8% among the women with elevated TSH, compared with 0.9% in women with TSH levels less than 6 mU/L (J. Med. Screen. 2000;7:127–30).

In another study by the same group of researchers, the results of IQ testing in children born to women who had untreated hypothyroidism during pregnancy were compared with those of children of women who had normal serum thyrotropin levels during pregnancy. Among the children of 48 women with untreated thyroid deficiency during pregnancy, the IQ scores were on average 7 points lower than those of the children of 124 women with normal thyroid levels. In addition, among children of mothers with untreated thyroid deficiency, 19% had IQ scores of 85 or less, compared with 5% of the other children (N. Engl. J. Med. 1999;341:549–55).

These are two bits of information that suggest that maternal hypothyroidism is a very serious condition and needs to be treated and monitored, said Dr. Lee, who had no commercial support to disclose.

Dr. Lee recommends TSH testing as soon as pregnancy is confirmed in women with a strong family history of hypothyroidism, who have a goiter on exam, or who were taking thyroid hormone prior to conception. She advises continuing to monitor these patients every 4–5 weeks through the first 20 weeks of gestation. After 20 weeks, the increased demand from the fetus seems to slow or stop, Dr. Lee said.

“Because these pregnant women do not see their [obstetricians] until week 12 or 13, it really is up to the internist to make sure that they know that they have to get the thyroid levels checked,” Dr. Lee said.

The Endocrine Society made similar recommendations in clinical practice guidelines released in 2007. The society advises physicians to measure TSH in women at high risk for thyroid disease.

PHILADELPHIA — Weight was once an afterthought in the treatment of diabetes, dyslipidemia, and hypertension, but that approach has now shifted, with many physicians seeing weight management as a first-line treatment.

But many physicians are still uncomfortable counseling their patients about nutrition and don't know what to recommend, Diana Cullum-Dugan said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS.

A range of diets have been studied in regard to weight loss efficacy and their effects on cholesterol and glucose. The best diet is the one patients will follow, said Ms. Cullum-Dugan, a registered dietitian who is in private in practice in Boston.

A study comparing the Atkins diet (very low carbohydrate, high fat), the Zone diet (moderate carbohydrate, moderate fat), Weight Watchers (high carbohydrate, moderate fat), and the Ornish diet (high carbohydrate, very low fat) and found that with each of the diets 20%-25% of subjects sustained modest weight loss beyond 1 year (JAMA 2005;293:43–53).

Ms. Cullum-Dugan tries not to focus on what patients are giving up, but instead, on what new, healthy foods they can add to their diets to feel full, such as olive oil, avocado, nuts, fruits, and vegetables. “Let those crowd out some of [the] high-fat choices they might make.”

In general, there is consensus around having a diet that is 30% fat, 40% carbohydrate, and 30% protein, with 25–38 g/day of fiber, Ms. Cullum-Dugan said. With a diet of less than 40% carbohydrates, patients risk having a diet with too much fat and not enough fiber, but if they fill 60%-65% of their diet with carbohydrates, they run the risk of not getting enough fat and protein.

Protein can include lean meats, fish, legumes, and low-fat dairy. Emerging data suggest protein plays a role in energy intake, satiety, and long-term weight loss (Diabetes Care 2004;27:S55–7).

Fat intake should be about 30%-35% of the total caloric intake, with less than 10% from saturated fats. Ms. Cullum-Dugan doesn't usually counsel patients to limit their fat intake unless they are obese but tries to help them choose foods with monosaturated fats and omega-3 polyunsaturated fats, such as nuts, olive and canola oil, flaxseed, and fish. She advises fish oil for those who won't eat fish.

Daily fiber intake should be 25–38 g/day, with the target for women at the lower end of that range and for men, at the upper end. Half cup of all-bran cereal, an apple, a half cup of broccoli, two slices of whole wheat bread, a pear, and a half cup of lentils make up around 28 g fiber.

Ms. Cullum-Dugan also tries to get patients away from just counting calories. She recommends they fill half their plate with vegetables, a quarter with protein, and a quarter with starches. She also advises consistency-patients should eat about the same amount of food at about the same time of day.

PHILADELPHIA — Weight was once an afterthought in the treatment of diabetes, dyslipidemia, and hypertension, but that approach has now shifted, with many physicians seeing weight management as a first-line treatment.

But many physicians are still uncomfortable counseling their patients about nutrition and don't know what to recommend, Diana Cullum-Dugan said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS.

A range of diets have been studied in regard to weight loss efficacy and their effects on cholesterol and glucose. The best diet is the one patients will follow, said Ms. Cullum-Dugan, a registered dietitian who is in private in practice in Boston.

A study comparing the Atkins diet (very low carbohydrate, high fat), the Zone diet (moderate carbohydrate, moderate fat), Weight Watchers (high carbohydrate, moderate fat), and the Ornish diet (high carbohydrate, very low fat) and found that with each of the diets 20%-25% of subjects sustained modest weight loss beyond 1 year (JAMA 2005;293:43–53).

Ms. Cullum-Dugan tries not to focus on what patients are giving up, but instead, on what new, healthy foods they can add to their diets to feel full, such as olive oil, avocado, nuts, fruits, and vegetables. “Let those crowd out some of [the] high-fat choices they might make.”

In general, there is consensus around having a diet that is 30% fat, 40% carbohydrate, and 30% protein, with 25–38 g/day of fiber, Ms. Cullum-Dugan said. With a diet of less than 40% carbohydrates, patients risk having a diet with too much fat and not enough fiber, but if they fill 60%-65% of their diet with carbohydrates, they run the risk of not getting enough fat and protein.

Protein can include lean meats, fish, legumes, and low-fat dairy. Emerging data suggest protein plays a role in energy intake, satiety, and long-term weight loss (Diabetes Care 2004;27:S55–7).

Fat intake should be about 30%-35% of the total caloric intake, with less than 10% from saturated fats. Ms. Cullum-Dugan doesn't usually counsel patients to limit their fat intake unless they are obese but tries to help them choose foods with monosaturated fats and omega-3 polyunsaturated fats, such as nuts, olive and canola oil, flaxseed, and fish. She advises fish oil for those who won't eat fish.

Daily fiber intake should be 25–38 g/day, with the target for women at the lower end of that range and for men, at the upper end. Half cup of all-bran cereal, an apple, a half cup of broccoli, two slices of whole wheat bread, a pear, and a half cup of lentils make up around 28 g fiber.

Ms. Cullum-Dugan also tries to get patients away from just counting calories. She recommends they fill half their plate with vegetables, a quarter with protein, and a quarter with starches. She also advises consistency-patients should eat about the same amount of food at about the same time of day.

PHILADELPHIA — Weight was once an afterthought in the treatment of diabetes, dyslipidemia, and hypertension, but that approach has now shifted, with many physicians seeing weight management as a first-line treatment.

But many physicians are still uncomfortable counseling their patients about nutrition and don't know what to recommend, Diana Cullum-Dugan said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS.

A range of diets have been studied in regard to weight loss efficacy and their effects on cholesterol and glucose. The best diet is the one patients will follow, said Ms. Cullum-Dugan, a registered dietitian who is in private in practice in Boston.

A study comparing the Atkins diet (very low carbohydrate, high fat), the Zone diet (moderate carbohydrate, moderate fat), Weight Watchers (high carbohydrate, moderate fat), and the Ornish diet (high carbohydrate, very low fat) and found that with each of the diets 20%-25% of subjects sustained modest weight loss beyond 1 year (JAMA 2005;293:43–53).

Ms. Cullum-Dugan tries not to focus on what patients are giving up, but instead, on what new, healthy foods they can add to their diets to feel full, such as olive oil, avocado, nuts, fruits, and vegetables. “Let those crowd out some of [the] high-fat choices they might make.”

In general, there is consensus around having a diet that is 30% fat, 40% carbohydrate, and 30% protein, with 25–38 g/day of fiber, Ms. Cullum-Dugan said. With a diet of less than 40% carbohydrates, patients risk having a diet with too much fat and not enough fiber, but if they fill 60%-65% of their diet with carbohydrates, they run the risk of not getting enough fat and protein.

Protein can include lean meats, fish, legumes, and low-fat dairy. Emerging data suggest protein plays a role in energy intake, satiety, and long-term weight loss (Diabetes Care 2004;27:S55–7).

Fat intake should be about 30%-35% of the total caloric intake, with less than 10% from saturated fats. Ms. Cullum-Dugan doesn't usually counsel patients to limit their fat intake unless they are obese but tries to help them choose foods with monosaturated fats and omega-3 polyunsaturated fats, such as nuts, olive and canola oil, flaxseed, and fish. She advises fish oil for those who won't eat fish.

Daily fiber intake should be 25–38 g/day, with the target for women at the lower end of that range and for men, at the upper end. Half cup of all-bran cereal, an apple, a half cup of broccoli, two slices of whole wheat bread, a pear, and a half cup of lentils make up around 28 g fiber.

Ms. Cullum-Dugan also tries to get patients away from just counting calories. She recommends they fill half their plate with vegetables, a quarter with protein, and a quarter with starches. She also advises consistency-patients should eat about the same amount of food at about the same time of day.

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan aimed at eliminating the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits.

Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden.

For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech in which he announced details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan essentially would destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but the organization has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research. The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election/

Sen. John McCain is in favor of allowing Americans to buy health insurance coverage across state lines. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan aimed at eliminating the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits.

Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden.

For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech in which he announced details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan essentially would destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but the organization has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research. The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election/

Sen. John McCain is in favor of allowing Americans to buy health insurance coverage across state lines. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan aimed at eliminating the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits.

Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden.

For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech in which he announced details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan essentially would destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs. The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but the organization has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research. The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election/

Sen. John McCain is in favor of allowing Americans to buy health insurance coverage across state lines. John McCain 2008/