This post was written by Maggie Mahar and Niko Karvounis

2007 marked the first time in 50 years that less than 20% of Americans smoked.  This is the good news. The bad news is that, just as the battle against smoking has entered what may be its most critical, final phase, support for that battle has waned among policymakers—even though the problem is far from solved.

Tobacco use, especially cigarette smoking, continues to be the leading cause of preventable diseases in the United States. It is blamed for 435,000 premature deaths in this country each year, and it adds more than $75 billion to annual spending on health care, according to the federal Centers for Diseases Control and Prevention.

Consider the raw numbers: in 2007, an estimated 19.8% (43.4 million) of US adults were still smoking cigarettes; of these, 77.8% (33.8 million) smoked every day, and 22.2% (9.6 million) smoked some days.  That’s a lot of smoke.

Break down the demographics and you find stark patterns. Smokers are likely to have less education than other Americans: CDC research has found that adults who have a GED diploma (44.0%) and those with 9–11 years of education (33.3%) are most likely to use tobacco.  Americans with an undergraduate or graduate degree are least likely (11.4% and 6.2%, respectively). Poorer people also are more likely to smoke: 33% of U.S. adults living below the poverty level are smokers while only 23.5% of those living above that level still light up.

Given how expensive cigarettes are these days, these are striking statistics. Why do low-income people smoke? Medical research shows that being poor is extremely stressful. You have less control over your life and must cope with much more uncertainty: Will you be able to pay your rent? What will you do if you lose your job? Are your children safe walking home from school?  As anyone who has ever been addicted to tobacco knows, being anxious makes you reach for a cigarette.

Military veterans under the care of the Department of Veterans Affairs (VA) health care system are also more likely to smoke than other Americans. Indeed, a 2004 report titled “VA in the Vanguard: Building on Success in Smoking Cessation” points out that “the prevalence of smoking is approximately 43 percent higher” among these veterans than in the general population.  “Many Americans who may have never smoked prior to their military service began smoking while in the service,” the report observes.  In the past, “ ‘Smoke ‘em if you‘ve got ‘em’ was a common command, and in many cases was even encouraged as it was thought to help keep soldiers alert and awake—or to help them cope with the tedium of waiting while on watch and the stress of combat.”

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Today, the Kaiser Network reported that on Friday, the Medicare Payment Advisory Commission (MedPac) approved a set of recommendations that would revise the current Medicare payment system, which was implemented in 1983, for hospice care providers serving terminally ill patients.  CQ HealthBeat reports that these recommendations will be included in a report to be issued in March to Congress and to take effect in 2013. (Thanks to Brad F. for calling my attention to this piece of news.)

Apparently, MedPAC has been concerned that for-profit businesses have been driving growth in Medicare spending by targeting hospice patients who need relatively long periods of care. The new payment system intends to remove incentives for long hospice stays.

So MedPac is recommending that Medicare change its payment system to include relatively higher payments per day at the beginning of the episode, and relatively lower payments per day as the length of the episode increases. 

Call me cynical, but do you suppose that would give for-profit hospices and incentive to toss patients out and send them home if they linger on too long? Alternatively, the hospice might encourage them to “let go”…

The whole idea of “for-profit hospices” strikes me as a truly terrible idea—right up there with “for-profit prisons” (which have not worked out well). 

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Like so many other federal agencies, the National Institutes of Health (NIH) has struggled under the Bush Administration, and today, it needs to be revitalized. Not long ago, I wrote about what we can expect for the FDA when president-elect Obama comes to office; now I’d like to turn the NIH. But to understand the agency’s future, one needs to recognize its recent past.

The Bush Years: Starving the Beast

From 1998 to 2003, the NIH enjoyed a golden age. Over that span, the agency’s budget doubled to $ $27 billion, an increase that Harvard University president Drew Faust has called a "transformative force for biomedical research.” But since 2003, NIH funding has remained essentially flat and, when adjusted for inflation, it has actually declined.

This has caused concern within the medical research community While 10 percent of the agency’s budget funds in-house research, a whopping 85 percent supports biological and medical research at universities and medical centers. When the NIH has less money, it has less money to give—and more researchers on the cusp of biomedical breakthroughs miss out on the funding they need.

Last year, the Group of Concerned Universities and Research Institutions (GCURI)—an association of seven top-tier universities including Harvard, Duke, Johns Hopkins, and Brown—issued a report arguing that reduced funding for NIH means “slowing the pace of medical advances, risking the future health of Americans, discouraging [the country’s] best and brightest researchers, and threatening America's global leadership in biomedical research.”

Indeed, as the NIH budget has shrunk, researchers have had a harder time securing grants: according to GCURI’s report, the agency funded 32 percent of proposed research projects in 1999, but only 24 percent in 2007. Researchers who are awarded NIH grants also have to jump through more hoops than they did in the past. In 1999, 29 percent of grant proposals were approved upon first submission; in 2007, only 12 percent of projects were given the same first-time approval.  These days, 88 percent of researchers who end up with NIH funding do so after applying multiple times. According to GCURI “this trend represents a clog in the system that is causing researchers to abandon promising work, downsize labs, and spend more time searching for other financial support. Meanwhile,” the report continues, “Americans wait longer for cures.”

There’s no reason to think that the quality of grant proposals between 1999 and 2007 has dropped precipitously enough to warrant a stingier NIH. Good scientists are being left high and dry. The agency’s primary research grant—the so-called R01 grant—is generally regarded as the “gold standard” in science: when the government grants an R01 to a project, that research is officially legitimated as important, ground-breaking work. In fact, GCURI claims that “a scientist is not considered established and independent until he or she is awarded an R01, which…enable[s] scientists to hire staff and buy [the] equipment and materials necessary to conduct experiments.” Or, as Dr. Denis Guttridge, Associate Professor at The Ohio State University, puts it: “assistant professors cannot get going in their careers until they get their first R01.” Thus allowing federal grant money for medical research to shrink puts our country at risk of “los[ing] a generation of committed scientists” and the medical breakthroughs that they can provide.

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According to the American Bar Association’s Commission on Legal Problems of the Elderly, the notion that everyone should have a living will is a “myth.”  

In theory, a living will gives healthcare providers a window on the patient’s wishes regarding end-of-life care, telling caregivers whether he wishes to be resuscitated, intubated, or artificially hydrated.

In practice, doctors who deal with the dying say that such wills rarely capture the complex realities of being critically ill. An article published today in American Medical News quotes Angela Fagerlin, an associate professor of internal medicine at the University of Michigan Medical School and co-author of a study of living wills published in the Archives of Internal Medicine: “There are so many contingencies in medical scenarios that you can’t put them all down in a living will. You’re putting a lot of undue pressure on surrogates to correctly interpret advance directives.”

Even the patient who makes out a will may not know what he wants. After illness and hospitalization, three in 10 patients adjust their views, desiring more or less aggressive care than they previously thought they wanted.  “If patients’ own preferences are so unstable, then how reliable are their advance directives as a guide to what they would have wanted?” AMNews asks.

“People have a hard time anticipating the care settings in which they’ll face decisions in the future,” says G. Caleb Alexander, assistant professor of medicine at the University of Chicago Pritzker School of Medicine. “You can quote Yogi Berra: ‘It’s tough to make predictions, especially about the future'.”

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By now you’ve probably heard the calls for speedy action on health care reform during the Obama Administration’s first hundred days. Some prominent observers even say that the President-elect should get the ball rolling during “his first days in office” The possibility of imminent health care reform is certainly exciting, but a word of caution: just because some of us might be ready for health care reform doesn’t mean that the media is ready to cover it properly. And that could have important implications for how reform plays out.

Right now, health care reform is an abstract goal that everyone wants. Excitement and anticipation are high. But as the substantive process of health care reform gets underway, two things will happen: first, ideas will be crafted into policies—concrete plans of action and complex administrative measures—and second, politicians will become involved in the reform process. Policy can get pretty complicated; so the public will rely on the media to help it navigate the ins and outs of the issue. Once politics begins to shape policy discussions—that is, once politicians enter the picture—it’s all the more important to keep the focus on policy, because it’s at this point that policies have a real chance of being implemented. Americans should know their options.

Style Over Substance

Unfortunately, reporters aren’t health care policy experts. In fact, they rarely ever talk about the issue. In a December report, the Kaiser Family Foundation found that, out of 3,513 health news stories in newspapers, on TV and radio, and online between January 2007 and June 2008, health care policy comprised less than one percent of news stories and just 27.4 percent of health-focused stories. Instead of talking about issues like coverage, prescription drug care, costs, or public programs, the media prefers to report on specific diseases and conditions (cancer, diabetes, obesity and heart disease) and potential epidemics (contaminated food and water, vaccines, binge drinking). Together, these two topics comprised 72.6 percent of health coverage.

This is less than ideal. When Congress begins to talk about health reform in earnest, the important news that will affect all of us will be about policy and institutional changes. The media needs to be good at covering this stuff—yet as the Kaiser report shows, news casters, reporters, and editors have very little experience (or interest) in discussing such issues. Worse, history shows that when health care reform efforts are actually underway, the media ignores policy in favor of more sensational stories.

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