Many sufferers of mesothelioma and other asbestos-related disease are on Medicare. You may have heard the health care reform bill now being debated in Congress includes cuts to Medicare. Will this pose a hardship on America’s seniors?

The House bill trims $440 billion from Medicare spending over the next ten years, and the Senate bill cuts $420 billion. Yes, that’s a lot of money. But it amounts to only about 3 percent of anticipated growth in the program. The wonks say this much can be trimmed without cutting benefits. Savings can be found by reducing waste, fraud, and inefficiencies, they say.

Some parts of the program might get better. For example, I wrote in the last post that the House and Senate bills both promise to close the “doughnut hole” in Medicare Part D that costs many seniors thousands of dollars in out-of-pocket prescription drug expenses.

The biggest question mark is over the Medicare Advantage program. Through Medicare Advantage, the government pays private insurance companies to enroll seniors in managed-care networks. The plans often come with perks not available through “plain” Medicare, such as dental and vision coverage and health club memberships. About a quarter of Medicare recipients are enrolled in Medicare Advantage.

The problem with Medicare Advantage is that it is burning a hole in the federal budget, an even bigger hole than regular Medicare. And much of that money is not benefiting seniors at all.

Medicare Advantage was created by Congress with the theory that private insurance companies would be able to manage seniors’ health care more efficiently than the government. It was supposed to save money, in other words. Conservatives pushed for Medicare Advantage as a way to “wean” seniors away from regular Medicare and eventually do away with the original program entirely. Former House Speaker Newt Gingrich liked to brag that Medicare would “wither and die on the vine.”

But today Medicare Advantage costs the government 14 percent more per person than regular Medicare. Why? Well, possibly because 15 percent of each dollar our government pays to the Medicare Advantage insurers goes into profits, marketing, and corporate expenses. This “overage” is nearly 10 times the rate of traditional Medicare.

According to Matt Sedensky of the Associated Press,

“Advantage companies were paying for multimillion-dollar corporate retreats in exotic locales and hundreds of their executives were being paid more than $500,000 annually. Government reports have shown Medicare Advantage providers continually outpace profit projections. The congressional review released this month showed 34 Advantage companies devoted $27 billion in government subsidies from 2005 through 2008 to profits, marketing cost and other corporate expenses.”

The fact is, the wasteful overpayments to Medicare Advantage that aren’t helping anyone but insurance company executives are putting the whole Medicare Program at risk. If nothing is done, deep cuts in benefits will have to be made. Pulitzer Prize-winning journalist Saul Friedman wrote, “But did you know that many of people on Medicare — more than 8.6 million of you — are inadvertently helping to kill Medicare?” He was talking about Medicare Advantage.

The House and Senate bills both provide for cutting the subsidies to Medicare Advantage and putting limits on the profits the private insurers can make. So, while there are not supposed to be cuts in benefits in regular Medicare, it’s possible there will be cuts in Medicare Advantage plans. But if nothing is done, the whole Medicare program will be in danger.

— Barbara O’Brien

Many obstacles and stumbling blocks remain in the way of health care reform. The House and Senate bills will have to be merged, and then the House and Senate both will vote on the final bill. We don’t yet know what will be in the final bill, or if the final bill will be passed into law. Passage will be especially difficult in the Senate, where it will need 60 votes to pass. It is still possible that after all this angst, just one grandstanding senator could kill the whole thing.

But just for fun, let’s look at what conventional wisdom says will be in the final bill and see if there is anything in it that will be an immediate benefit to people with mesothelioma and other asbestos-related disease.

It is likely that the final bill will provide additional funding for state high-risk insurance pools. Currently more than 30 states run such pools, which are nonprofit, state-sponsored health insurance plans for people who can’t buy insurance because of pre-existing conditions. The biggest problem with such pools is that, often, the insurance they offer is too expensive for many who might need it. Both the Senate and House bills provide $5 billion in subsidies for state high-risk pools to make the insurance more affordable.

Under the Senate bill, beginning in 2014, private companies would no longer be able to deny coverage to adults with pre-existing conditions, nor could they charge higher premiums for people with pre-existing conditions. Until then, the state high-risk pools could provide some help.

Closing the Medicare Part D coverage gap — also called the “doughnut hole” — is another potential provision that could help some patients with asbestos-related disease. The “doughnut hole” is the gap between the coverage for yearly out-of-pocket expenses provided by Medicare Part D and Medicare’s “catastrophic coverage” threshold.

For example, in 2009 Medicare Part D paid at least 75 percent of what patients paid for prescription drugs up to $2,700. After that, patients must pay for all of their prescription medications until what they have paid exceeds $6,154. At that point, the catastrophic coverage takes over, and Medicare pays for all but 5 percent of the patient’s drug bills. The final health care reform bill probably will provide for paying at least 50 percent of out-of-pocket costs in the doughnut hole.

You may have heard the bills include budget cuts to the Medicare program, and this has been a big concern to many people. Proponents of the bill insist that savings can be found to pay for the cuts, and that people who depend on Medicare won’t face reduced services. But this is a complex issue that I want to address in a later post.

The long-term provisions probably will include many other provisions that would benefit patients with asbestos-related disease, including increased funding for medical research. Although there are many complaints about the bill coming from all parts of the political spectrum, on the whole it would be a huge benefit to many people.

— Barbara O’Brien

Among the “sweeteners” added to the Senate health care reform bill is a proposal to extend Medicare for certain individuals exposed to environmental health hazards. And not just any environmental health hazards; in particular, health hazards that were recognized as a public health emergency in a declaration issued by the federal government on June 17. Yes, that would be Libby, Montana.

Libby was contaminated over a period of several decades by mining operations of the W.R. Grace Company. The company took vermiculite laced with asbestos out of the ground near Libby, and in the process asbestos was scattered for miles throughout the community. Hundreds of people have died of mesothelioma and other deadly diseases as a result of the asbestos exposure in Libby, and thousands have been diagnosed with asbestos-related disease.

The plight of the people of Libby was ignored for decades. The EPA began a cleanup in 2000, which is still in progress, but people were, and still are, getting sick, and many have lost homes and businesses because of the contamination. It was not until this past June that any substantive help was appropriated for the people of Libby — a “public health emergency” was issued, and money was set aside to provide some health care to stricken Libby residents.

Enter Sen. Max Baucus of Montana, chairman of the Senate Finance Committee. Baucus held the Senate health care reform bill in his committee for a long time, and he had a big hand in crafting the bill. Some feel Baucus’s dithering weakened the bill; others think his influence made it more cost-effective. Even so, Baucus made noises about not supporting the bill until he was awarded some concessions, and these included the Medicare provision for Libby.

Baucus told Robert Pear of the New York Times: “The people of Libby were poisoned and have been dying for more than a decade. New residents continue to get sick all the time. Public health tragedies like this could happen in any town in America. We need this type of mechanism to help people when they need it most.”

One person’s blessing is another’s boondoggle. People opposed to the health care bill call the Libby provision “pork.” One might argue that specific provisions like this one, however beneficial, should not be part of the federal health care reform bill. But let’s look at the bigger picture.

The party that caused the contamination, the W.R. Grace Company, has largely escaped penalty. This past year the company and three former executives were acquitted of knowingly causing the deadly contamination and covering up their actions. The company did, for a time, pay for the health care of Libby residents who were diagnosed with asbestos-related disease, but the company’s efforts fell far short of what was needed.

The bottom line is that in the case of environmental and public health disasters such as Libby’s, we as a nation have two choices — ignore them, and let the victims fend for themselves, or step up to take care of the problem. And taking care of the problem means somebody’s got to pay for it, either private business or taxpayers.

— Barbara O’Brien

Here’s an eye-popping statistic — every year in the United States, $210 billion is wasted on medical paperwork. That’s according to a recent study by PricewaterhouseCoopers. Physicians, clinics and hospitals must deal with hundreds of different health care companies, each offering a multitude of plans. If federal health care reform does nothing but impose a uniform billing system, all those billions could be saved.

Where else are our health care dollars wasted? As an article in the current issue of Newsweek points out, most hospitals are organized by traditional specialties; each department in the hospital operates with its own record keeping and business practices. When Duke University Medical Center set up a disease management system that coordinated the work of primary care physicians, specialists, pharmacists, and other hospital staff, costs were reduced by 40 percent and patient outcomes improved.

The point is that our patchwork healthcare “system,” if it rises to the level of being a “system,” wastes money all kinds of ways. Many pundits and politicians are obsessed with the idea that medical malpractice is the chief cause of rising health care cost. And a recent Congressional Budget Office review concluded that tort reforms would save the federal budget about $54 billion over ten years. Huzzah! yelled the pundits. Problem solved!

But the same CBO analysis also explained that these savings would amount to only about 2 percent of the nation’s health care costs. Further, because most states already have “reformed” tort law, a substantial amount of the $54 billion is already being saved (see page 4).

Comparing $54 billion over ten years with $210 in one year ought to tell us that uniform billing is a much bigger priority than tort reform. But no lobbyists are being paid to push for uniform billing practices, so we don’t hear about it as much. That’s how Washington works.

People suffering from asbestos-related diseases like mesothelioma need good health care, and they also need to be able to seek damages in court to get the money they need to take care of themselves and their families. There is no reason to sacrifice the rights of Americans to seek justice in courts in order to lower health care costs.

— Barbara O’Brien

A doctor writes that a malpractice case recently was filed against him, and he thinks the suit is unjust. “I reviewed my medical records and felt comfortable with the care I had provided,” he says. However, he wonders if he can document that he did what was best for the patient. He wonders if what he did conforms to “community standards” of medicine, which he says are determined by lawyers instead of doctors. And he sincerely believes that having to be on guard against nuisance lawsuits wastes time and money and compromises medical care.

Let’s give this doctor the benefit of the doubt and assume he did provide good care. He doesn’t discuss the case, but we have to assume the patient, or the patient’s survivors, were not happy with the outcome of care and sincerely believe the physician must have done something wrong. Maybe their beliefs are unfounded, but they believe what they believe. And they go to a lawyer and tell him their side of the story.

Malpractice law varies from state to state. However, just because a doctor made a mistake doesn’t make him guilty of malpractice. Usually there has to be genuine misconduct, meaning the doctor did something outside the common and reasonable standard of medical care. But physicians complain the standards are not exactly written in stone anywhere. What seems reasonable in a hospital can be made to look unreasonable in a courtroom.

Lawyers also are working in the dark. The patient’s medical records may be ambiguous and not tell the whole story. The lawyer may have to subpoena other records, or take depositions, before he knows for certain if the case has merit. In other words, sometimes legal procedures have to be used to find out what really happened. Physicians counter that such investigations cost everyone time and money.

The “tort reform” solution is to cap damages and place a larger burden on plaintiff for filing suit. But this solution puts all the burden of “reform” on the backs of patients who really were injured. Is that fair? Are there other ways to take some of the stress and expense out of the med-mal system?

Some suggest that doctors should get together and adopt transparent standard guidelines for treatment so that everyone knows what the standards are. If a patient suspects malpractice, the physician would only have to provide documentation that he followed these doctor-determined guidelines to put an end to the inquiry. Some situations will not fit standard models, of course, but taking such a step would reduce some of physicians’ anxieties about being sued, I would think.

A 2006 Harvard University study of malpractice found that 37 percent of malpractice plaintiffs failed to prove that a doctor was at fault. Most of those plaintiffs received no compensation, meaning their lawyers probably weren’t paid, either. It might be that both doctors and lawyers would appreciate some clarity on the issue of what is standard practice and what isn’t. However, capping jury awards doesn’t accomplish that.

Tort reform is a critical issue for people suffering from mesothelioma and other asbestos-related diseases. It is a near certainty that such people were exposed to asbestos on the job or by handing an unsafe product, meaning that someone else’s negligence caused the disease. Most tort reform proposals would make it more difficult for asbestos victims to sue for damages and would also limit the awards they might receive. Is this fair?

The doctor I spoke of in the first paragraph writes, “How does anyone credibly defend a system that targets innocent physicians routinely, vaporizes tens of billions of dollars on defensive medicine and misses the vast majority of patients who have been the victims of true negligence?” To which I would ask, how does capping jury awards make the system fairer? Isn’t there another way?

Every day, American newspapers and other news media crank out a new supply of editorials calling for tort reform. Every day, there are new accusations that millions of dollars are wasted by “frivolous” lawsuits filed by “greedy” litigants and predatory lawyers. These so-called “greedy” litigants include people suffering from mesothelioma and other deadly diseases caused by asbestos exposure.

You can pretty much count on the words “frivolous” and “greedy” appearing at least once in every editorial. A new rhetorical twist that has been popping up lately is likening personal injury lawyers to drug dealers. It’s as if all these editorialists are writing from the same set of notes.

Oddly, it’s hard to find a similar number of fire-and-brimstone editorials raging against malpractice. Yet a 2006 study by the Institute of Medicine showed that medication errors alone injure 1.5 million people and cost billions of dollars every year. Why aren’t we seeing as much outrage about “sloppy” doctors and pharmacists?

Often doctors are duped by “duplicitous” pharmaceutical companies into prescribing dangerous drugs that patients don’t really need. In recent years about 13,000 people have sued Wyeth Pharmaceuticals, claiming that drugs taken to relieve symptoms of menopause caused breast cancer and other problems. Wyeth manufactures the hormone replacement drugs Premarin and Prempro, which in 2001 earned the company almost $2 billion in sales.

Many physicians were persuaded to prescribe Premarin and Prempro because articles favorable to the drugs were published in medical journals. But it turns out that Wyeth was paying ghostwriters to plant the articles in the journals. Respected physicians often were paid to put their names on the articles even though they didn’t write them.

The articles claimed the drugs not only relieved menopause symptoms but also provided some protection from other effects of aging, such as dementia and heart disease. So for a while American physicians routinely prescribed these drugs for their patients experiencing menopause.

But it turns out that the drugs actually increase the risk of dementia and heart disease as well as breast cancer. And litigants’ attorneys have discovered that Wyeth was aware of studies conducted in the 1970s that linked Premarin to endometrial cancer and studies in the 1990s that linked Prempro to breast cancer. But the public, and most physicians, were unaware of these studies.

Finally, in 2002 a major clinical trial was halted when the researchers realized that women taking the hormone replacement therapies had a higher rate of breast cancer, heart disease, stroke, and blood clots in the lungs compared to women taking placebos. After that, sales of menopause drugs plummeted. But for many women the damage was already done.

Recently a jury in Pennsylvania ordered Wyeth to pay $75 million in punitive damages to a woman who took Prempro and developed breast cancer. According to “tort reformers,” such awards are bad for the economy and increase health care costs, and must be stopped.

But what remedy do they recommend? “Tort reformers” say the law should protect Wyeth from having to pay damages to the women who developed breast cancer and other problems. In other words, their remedy is not to find ways to prevent reckless practices that injure and kill people, but to protect companies like Wyeth from liability. In what universe does that make sense?

An old American cruise ship sent to India to be demolished has set off a minor international incident. The government of India has barred the ship from its ports, calling it an environmental hazard, and has accused the owners of falsifying the ship’s flag and registration. The incident not only points up the toxic dangers found in old ships but also the horrors of the “ship breaking” business in India.

The ship, currently called the Platinum-II, is said to be contaminated by a number of toxic chemicals as well as asbestos, known to cause asbestos cancer. Her owners were trying to get her to the “ship breaking” yards in Alang, on the northwest coast of India. It is said the shipyards at Alang recycle about half of all ships salvaged around the world.

But the work there is done with primitive equipment and with no safety precautions. Three years ago a study commissioned by the Indian government showed that one in six workers at the Alang shipyard had symptoms of asbestos poisoning.

It appears the current owners were trying to scrap the vessel on the cheap, and got caught.

The BBC mistakenly identified the Platinum-II, a.k.a. the S.S. Independence or the S.S. Oceanic, as a former U.S. Navy vessel, but she was never in the military. Built in 1951 as a cargo vessel, she was rebuilt in 1959 as a luxury cruise ship complete with handsome penthouses and Fifth Avenue shops. She was owned by American Hawaii Cruises, and she sailed under the name S.S. Independence, although for a time she was the S.S. Oceanic Independence.

After American Hawaii Cruises went bankrupt in 2001 she became the property of the U.S. Maritime Administration. She was sold at auction to Norwegian Cruise Lines in 2003. In 2007 Norwegian Cruise Lines announced that the ship was sold again, but after that her history gets murky.

At some point her last known owner, Global Marketing Systems, was fined $518,500 for exporting the ship for scrap without prior removal of toxins such as asbestos and PCBs. It is not clear from news stories whether Global Marketing Systems still owns the ship. In any event, it may be that the cost of removing toxins is higher than what the ship might be worth as scrap, which would provide a powerful incentive to get the ship demolished without bothering with the toxin removal.

Renamed the Oceanic, in 2008 the ship was towed out of San Francisco. Her destination was supposed to be Singapore, but instead she was taken to Dubai. Where the ship is now and what might happen to her next are not clear.

[Image Credit: Christopher Glase, Stock.xchange]

— Barbara O’Brien

Every day, old ships are moved to dry dock for repair. But when the old ship is the venerable U.S.S. Missouri, news bureaus around the world take notice.

At dawn on October 14, 2009, a crowd gathered on the shore just to watch the famous World War II battleship move through the water. Slowly, tugboats turned the 887-foot ship and towed it two miles to the Pearl Harbor Naval Shipyard Dry Dock, where three months’ work and $18 million will give the rusting, aging vessel a more seaworthy appearance.

Since 1998, the U.S.S. Missouri has been moored near the U.S.S. Arizona Memorial, which marks the place where the Arizona rests at the bottom of Pearl Harbor, Hawaii. The Arizona was destroyed by the Japanese attack of December 7, 1941, an event that marked the entry of the United States into World War II. The U.S.S. Missouri sailed into Tokyo Bay on August 29, 1945, to serve as the site for Japan’s formal surrender.

The casualties of war didn’t end with the surrender. Today, many veterans suffer from asbestos-related diseases like mesothelioma as a result of their work on ships and in shipyards. As we struggle to care for ailing veterans, however, we should not forget to honor the service they gave to their country. Building the great ships of war was a vital part of that service.

The Mighty Mo was built at the Brooklyn Navy Yard. Margaret Truman, President Harry Truman’s daughter, christened her when she was launched in January, 1944. Her main battery —16 in (410 mm)/50 cal Mark 7 guns, which could fire 2,700 lb. armor-piercing shells a distance of 20 miles — supported the Marines landing at Iwo Jima. She also played a critical role in the invasion of Okinawa. A kamikaze left a dent in her side that is visible to this day. But she is best remembered as the place where World War II formally, finally, came to an end.

After World War II, the other Iowa-class battleships were decommissioned. But President Truman ordered that the Missouri remain active, partly because of his personal fondness for the ship. The Mighty Mo saw action in the Korean War. Then, in 1955, President Dwight Eisenhower had her decommissioned, and for nearly thirty years she was moored at the Puget Sound Naval Shipyard.

President Ronald Reagan chose to bring the Missouri back to active duty in 1984. She was towed to the Long Beach Naval Shipyard and updated with the most advanced weaponry of the day. Her last wartime service was to provide naval support for Operation Desert Storm, Kuwait, 1991. In that effort she launched Tomahawk cruise missiles, but she also fired her big 410 mm guns for the first time since Korea.

Mighty Mo was decommissioned again in 1992 and taken back to moorings in Puget Sound. In 1998 she was towed to Pearl Harbor and moored with her bow facing the last resting place of the Arizona.

Lawrence Downes wrote for the New York Times that the Missouri, once the world’s deadliest instrument of total war, is now “a gathering place for tourists, sailors and schoolchildren. Her main duty now is to preserve the great moment that took place on her deck, so different from today, when a global war with a beginning and a middle finally came to an end.”

— Barbara O’Brien

(Photo of U.S.S. Missouri: U.S. Navy photo by Mass Communication Specialist 2nd Mark Logico/Released; October 14, 2009)

Last June, the Environmental Protection Agency declared a public emergency in Libby, Montana. The Seattle Post-Intelligencer first reported on the asbestos contamination of Libby in November, 1999, and at that time at least 192 people had died and another 375 had been diagnosed with fatal asbestos-related diseases. So the “emergency” was an old one, but better late than never.

Now Mount Sinai Hospital in New York is launching three investigations into asbestos-related disease in Libby. These diseases are unusually aggressive in Libby, said chief investigator Dr. Stephen Levin. The rates of cancer and other lung problems are even higher in Libby than in other asbestos exposure cases.

The first investigation will look at the risks to the children in the Libby community. The second will look at lung scarring in Libby residents who did not work in the mine. The third will look at a possible connection between lung scarring and auto-immune disorders, such as rheumatoid arthritis and lupus.

The contamination of the Libby community is so extensive that all residents are in danger, including people who never worked in the mine or processing plant. Residents were exposed to asbestos in the air and also through contaminated materials used to build ball fields, school running tracks, playgrounds, public buildings and facilities, and private residences.

Even low-level exposures to Libby asbestos appears to cause serious scarring and lung diseases as well as asbestos cancers like mesothelioma, which occur at higher rates among the Libby population. Libby residents also have an unusually high number of auto-immune diseases, meaning that they have an unusually high rate of antibodies to their own tissues.

The vermiculite mined in Libby since the 1920s is contaminated with tremolite asbestos, which has sharp, needle-like fibers. Through the years these fibers were spread throughout the community and the surrounding forests. The vermiculite from Libby was processed, packaged and sold throughout the United States as attic insulation, fireproofing and soil conditioner by the W.R. Grace company. The U.S. Environmental Protection Agency believes that about 35 million homes in America contain Libby vermiculite insulation, which has the brand name Zonolite. And in a spectacularly mishandled trial, federal prosecutors failed to get convictions against the company and former executives for causing the contamination.

— Barbara O’Brien

Today most big tobacco companies acknowledge there is a link between tobacco use and cancer. But you might remember that for years they denied any such link. In 2006, a federal district court judge found that the tobacco industry had known for 50 years that smoking was bad for health. “They mounted a coordinated, well financed, sophisticated public relations campaign to attack and distort the scientific evidence demonstrating the relationship between smoking and disease,” Judge Gladys Kessler said.

You may not know that asbestos manufacturers pulled exactly the same scam with the dangers of asbestos — in particular, the link between asbestos and the deadly lung cancer mesothelioma.

There were suspicions about asbestos back in the days of the Roman Empire, and many 19th century physicians observed that asbestos seemed to cause lung problems. But the modern struggle for the truth about asbestos began in the 1960s, when a physician named Dr. Irving Selikoff published case studies of asbestos cancer victims.

Dr. Selikoff was practicing general medicine Patterson, New Jersey, when the Asbestos Workers Union asked him to treat its members. The doctor soon noticed that a remarkable number of asbestos workers suffered from mesothelioma, considered to be a rare disease.

In 1963, Selikoff published his research showing the link between asbestos and mesothelioma in the Journal of the American Medical Association. Other researchers had suggested this link before, but the scope and thoroughness of Selikoff’s study persuaded many people that asbestos had to be restricted. Dr. Selikoff continued to publish and speak out on the dangers of asbestos. His work caused the Occupational Safety and Health Administration (OSHA) to establish workplace safety protocols for asbestos for the first time.

The asbestos industry did not only deny the connection; it also launched a vicious attack against Dr. Selikoff. His research was publicly belittled, and industry lawyers sent him letters threatening lawsuits. However, Irving Selikoff did not back down.

Asbestos companies even hired investigators to put Dr. Selikoff under surveillance, hoping to find a way to smear him. In 1965, some industry spokespeople claimed Dr. Selikoff was an immigrant (in fact, he was born in New York City in 1935) and that he was licensed to practice in a foreign country, not the United States (he went to medical school in Scotland but was licensed in the U.S.). When Dr. Selikoff was named director of the Environmental and Occupational Health Division of Mount Sinai Hospital in New York, the asbestos industry pressured Mount Sinai to fire him. Mount Sinai did not comply.

Dr. Selikoff died in 1992, yet the attacks did not stop with his death. Thirteen years after he died, a British historian and asbestos industry litigation consultant falsely claimed that Selikoff had never obtained a medical degree.

Most critically, the asbestos industry hired scientists to cast doubt on Dr. Selikoff’s work. This is the practice of “mercenary science” I’ve written about before. Several asbestos companies used a public relations firm to form the Asbestos Information Association, which existed to belittle research connecting asbestos to mesothelioma. Their hired scientists concluded that there was insufficient proof that chrysotile asbestos, the type most commonly used in manufacturing, was dangerous.

OSHA has so far refused to adopt this standard. Yet the fight continues, in spite of much more data showing a clear connection between asbestos of all forms and mesothelioma.