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This guide, designed to help you and your parents sort through basic issues about Medicare and health coverage, was written by the Medicare Rights Center in collaboration with the Henry J. Kaiser Family Foundation and was updated in 2003.

The Henry J. Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries.

Medicare Rights Center is a national, not-for-profit consumer service organization that helps people understand Medicare rights, benefits, and options. Through hotline counseling, education, and public policy programs, Medicare Rights Center works to ensure that seniors and people with disabilities get the health care they need and the coverage they are due.

The authors wish to thank the following individuals for their contributions: Eric Carlson, Geraldine Dallek, Joyce Dubow, Claire Edwards, Barbara Manard, Patricia McGinnis, Teresa McMeans, and Patricia Nemore. The guide was edited by Lynn L. Lewis and the Stein Group, and designed by Supon Design Group, formerly Gibson Creative. This website was developed by Words Pictures Ideas.

The Henry J. Kaiser Family Foundation

In Philadelphia, Malpractice Awards have ‘Gone Haywire’

Recent verdicts trouble insurance experts and drive out good doctors, many say.

12/10/2000

By Karl Stark Reprinted with permission of The Philadelphia Inquirer

The case was heartbreaking. A baby girl born so premature, she could fit in the palm of her mother’s hand. The surgeon, who operated to seal a blood vessel meant to close naturally after birth, could not find the correct vessel to seal. The child, who seemed to thrive at first, developed severe brain damage – in part because a nurse inserted a catheter in the wrong artery. The girl’s left arm later had to be amputated.

The attorneys squabbled mightily over who was at fault in the care of Alys Vlazny, now 5.

Six weeks ago, a Philadelphia jury delivered a malpractice verdict of $100 million against four doctors and two hospitals, St. Luke’s Hospital in Bethlehem, Pa., and St. Christopher’s Hospital for Children in Philadelphia. The award, which comes to $118 million with interest, represents the largest medical malpractice verdict in Pennsylvania history and one of the largest in the country.

Horsham-based Jury Verdict Research, which tracks malpractice cases nationwide, could cite only two larger awards in the last 10 years, both in New York.

The $100 million verdict, which lawyers are still contesting, has become exhibit A in a debate about surging malpractice judgments in Philadelphia. Juries here have returned awards of $55 million and $49.6 million within the last three months. The $100 million verdict on Oct. 20 was about five times larger than the largest malpractice judgment in Philadelphia as recently as a year ago.

“Philadelphia has gone haywire,” said Sarah H. Lawhorne, president of PMSLIC, the state’s largest malpractice insurer.

Thomas Gaudiosi, an executive with that company who oversees management of malpractice risk, said the city’s jurors have the mentality of contestants on the game show Who Wants to Be A Millionaire?

“Juries just are getting to the point of thinking when they give away money, it has no consequence,” said Benjamin Post, a malpractice defense lawyer in Philadelphia.

But there are consequences, insurers and defense lawyers say. They predict that the recent spike in awards here, even when covered by insurance and even when reduced on appeal, will jack up the cost of settling all cases.

“It encourages everyone to aim higher,” malpractice defense attorney Fredric L. Goldfein said.

Doctors say large jury awards could ultimately weaken Philadelphia’s medical institutions, driving out cutting-edge physicians or keeping them from ever coming here. Those who stay will face huge increases in their premiums next year, rate hikes that will exceed 50 percent for some doctors.

The city has long been a malpractice hot spot. Mostly because of Philadelphia, Pennsylvania ranks second in the nation, behind New York, in total malpractice payouts, according to data collected by the National Association of Insurance Commissioners.

Malpractice cases in Philadelphia generated more payout in 1998 than did those in California, where strict rules restrict awards, the association’s data show.

The big verdicts in Philadelphia underscore the need for the state legislature to limit malpractice awards, many in the medical community say.

“We have virtually none of the tort reforms that other states have,” said Andrew Wigglesworth, president of the Delaware Valley Healthcare Council, which represents hospitals. “We need an equitable system that compensates people fairly but doesn’t result in excessive awards that, as a society, we can’t sustain.”

Lawyers representing injured patients say more rules are not needed. Philadelphia generates more malpractice cases than the norm because this area – with its five medical schools and several eminent teaching hospitals – attracts patients from far beyond the Delaware Valley.

Big verdicts are usually corrected. Upon review, judges often reduce awards they think were made based on emotion. “Let the courts do their job,” said Gerald McHugh, a malpractice plaintiff lawyer in Philadelphia who has lobbied the legislature to protect patients’ rights.

Verdicts are increasing along with the cost of medicine, which has risen faster than overall inflation. Severely ill or disabled clients, who win many of the largest judgments, now require upward of $400,000 a year in care and can expect to live 40 years or more.

Some lawyers blame the biggest verdicts on insurers who don’t compromise out of court.

“It’s a crisis of their own creation,” said James E. Beasley Sr., a longtime plaintiff lawyer.

Beasley reached a $7.5 million settlement on Oct. 18 with Children’s Hospital of Philadelphia for a brain-damaged child. The settlement attracted attention because the jury, unaware that the settlement had been reached, returned with a $55 million verdict. Beasley said the $7.5 million agreement was made so late in the jury’s deliberations that he was not able to tell the court before the jury returned.

Beasley said the child’s mother had insisted on settling the case. “The jury questions got her upset” and she feared the jury would rule against her, Beasley said.

Lawyers who bring malpractice suits say the odds are against them, even in Philadelphia. In 1999, malpractice lawyers won 45 percent of the cases that went to trial; hospitals and doctors won the remainder, according to a study conducted by Philadelphia chief Administrative Judge John W. Herron. Philadelphia’s results are in line with the rest of the country, Herron said.

Insurers and opposing lawyers agree on one point. More serious medical mistakes seem to be on the horizon. Doctors have to practice medicine faster, and hospitals have reduced staff to save money. “You don’t pay less and get better as a general concept,” Lawhorne, the insurance company executive, said.

Shanin Specter, a malpractice lawyer in Philadelphia, agreed, saying: “It’s hard not to think that the general pressures of health care have played a significant role” in large verdicts. Specter convinced a jury that doctors at Temple’s Neumann Medical Center in 1997 had incorrectly inserted a tracheal tube to aid the breathing of David Caruso, 23, a record-store clerk from Port Richmond. Caruso suffered brain damage when the tube later became dislodged.

“The defense of the doctors was to blame the hospital,” Specter said. He won a $49.6 million verdict in August that was briefly the state’s largest. The case has been resolved for less than $10 million.

Thomas Kline, Specter’s law partner, said limiting awards would not protect patients. “The capping of liability invites unacceptable negligent conduct,” he said.

Doctors say they are penalized financially just by doing their jobs, especially in Philadelphia and Delaware County. Malpractice rates in this region for high-risk specialties – such as OB-GYN, orthopedics and neurosurgery – are often nearly double what the same doctors pay in Pittsburgh, and are 15 percent to 25 percent above rates in New Jersey, PMSLIC records show.

The big verdicts would command attention at any time. But this year, insurers are starting to pay off the failure of two large malpractice insurers. The spike in large awards has coincided with a double-digit rise in malpractice rates for many caregivers in Pennsylvania. Doctors’ basic malpractice rates for the first $500,000 of coverage will rise by an average of 25 percent to 30 percent in the coming year, said Randy L. Rohrbaugh, acting deputy commissioner of the Pennsylvania Department of Insurance.

The next layer of protection, from $500,000 to $1.2 million, is covered by a state agency, the Medical Professional Liability Catastrophe Loss Fund. The statewide “CAT” fund has seen its payout jump 27 percent over the last two years to $341 million. About 55 percent of that was spent just covering Philadelphia cases.

Now the fund will pass along those increases by raising rates next year an average of 26 percent for all doctors, with charges for oncologists and infectious-disease doctors rising by more than 50 percent.

Malpractice has helped drive some doctors from the field. Ronald J. Bolognese, chairman of Obstetrics and Gynecology at Jefferson Medical College, had been delivering babies one day a week but recently stopped because he said he wasn’t even covering his insurance premiums. Bolognese saved almost $60,000 in premiums, but he regrets losing that personal connection to patients.

Malpractice and other pressures also make it very difficult to attract talented newcomers to Philadelphia, said cardiologist Francis L. “Chip” Uricchio, who heads the 25-doctor Pennsylvania Heart and Vascular Group, based in Northeast Philadelphia. “We haven’t hired anybody since 1995,” he said, citing malpractice rates as one important factor.

The malpractice market is also bleak for hospitals. Gerald Miller, president of the Crozer-Keystone Health System, said he knows of two hospital systems whose malpractice costs doubled despite having no significant claims.

The new costs will put some hospitals in the red, Miller said.

In the $100 million verdict, St. Luke’s Hospital of Bethlehem is liable for $90 million of the judgment and could face bankruptcy if the full judgment stands. But experts say that is unlikely. Judgments are often limited to the hospitals’ insurance coverage because a greater amount can be complex and time-consuming to collect.

The case remains far from over. In a statement, St. Luke’s vowed to appeal and complained that “damage awards that shock the conscience have become common in the Philadelphia jurisdiction.”

John H. Reed, director of the state “CAT” Fund, said he still hoped to find common ground. The child could be compensated without subjecting defendants to the “economic death penalty in Philadelphia,” he wrote to the court.

“Injured parties can be protected through reasonable compensation without bankrupting the health-care system.”

Kaiser Media Fellowships program sitevisit to Menlo Park, CA:Thursday, January 24-Tuesday, January 29, 2002

Accommodations: The Stanford Park Hotel, 100 El Camino Real, Menlo Park, CA 94025(Tel: 650-322-1234; fax: 650-322-0975)

Thursday, January 24

6:30pm: Meet in hotel lobby 7:00pm: Dinner, Left at Albuquerque 445 Emerson Road, Palo Alto (Tel: 650-326-1011)

Friday, January 25

–Health/business issues 8:15am: Depart hotel for Kaiser Foundation 2400 Sand Hill Road, Menlo Park (Tel: 650-854-9400: fax: 650-854-4800) 8:30am: Buffet breakfast-Quadrus Conference Room 9:00am: Penny Duckham, executive director, Kaiser media fellowships program –Welcome and introduction 9:05am: Drew Altman, PhD, president and CEO, Kaiser Foundation –Rising health care costs, and health insurance issues 9:45am: Break 10:00am-11:30am: Prescription drug expenditures; advertising to consumers and physicians; impact of advertising on consumers–presentations, discussion –Larry Levitt, vice president, Kaiser Foundation; director, changing healthcare marketplace project and California health policy program –Mollyann Brodie, PhD, vice president, Kaiser Foundation; director, public opinion and media research 11:30am: Buffet lunch 12:00pm-1:15pm: Irene Ibarra, executive officer, Alameda Alliance for Health-Medicaid managed care: the impact of rising health care costs, prescription drug expenditures, on low-income patients 1:15pm-4:00pm: Patients’ rights in California-presentations, Q&A –Daniel Zingale, director, CA State Department of Managed Care –Walter Zelman, president & CEO, California Association of Health Plans 4:30pm: Depart Kaiser Foundation for hotel 6:30pm: Hors d’oeuvre & cocktail reception; 7:00pm: dinner The California Caf

The Henry J. Kaiser Family Foundation

2000 Kaiser Media Fellowships Program

First Meeting of 2000 Fellows and Fellowship Program Advisory CommitteeWednesday, September 27–Friday, September 29, 2000Hotel Accommodations: The Stanford Park Hotel, 100 El Camino Real, Menlo Park, CA 94025(Tel: 650-322-1234; fax: 650-322-0975)

Wednesday, September 27 6:40pm: Meet in hotel lobby 7:00pm: Dinner, 40 Tevis Place, Palo Alto Thursday, September 28 8:00am: Depart hotel by van for Kaiser Foundation 2400 Sand Hill Road, Menlo Park (Tel: 650-854-9400; fax: 650-854-4800) 8:30am: Buffet breakfast, Board Room–Introduction to the Kaiser Foundation:Drew Altman, president–Online health information/demonstration of Kaiser Health Information Network: Marla Bolotsky, director, online information 10:15/10:30am: Depart by van for Native American Health Center 3124 International Boulevard, Oakland, CA 94601 11:45am: Welcome–Martin Waukazoo, CEO, Native American Health Center, and colleagues (e-mail: martinw@uihbi.org) 12:15pm-2:30pm: : Briefing/Working lunch; tour of clinicOverview briefing–Native American health issues, withJames Crouch, executive director, California Rural Indian Health Board 4:00pm: Depart by van for hotel, Palo Alto 6:40pm: Walk/drive to California Caf

The Henry J. Kaiser Family Foundation

Continuing Fight on Capitol Hill over a Patients Bill of Rights

05/11/2000

Anchor: Bob Edwards; Reporter: Joe Palca Reprinted with permission of National Public Radio

To listen to this segment, please visit the NPR web site.

This is NPR’s MORNING EDITION. I’m Bob Edwards.

President Clinton today is meeting with congressional negotiators at the White House to try to break the stalemate over a Patients Bill of Rights. Last year, the House and Senate passed significantly different versions of the bill and there have been few signs of compromise. One of the sticking points is insurance coverage for medical research studies. The insurance industry maintains they should not be forced to pay for studies of unproven therapies, but researchers argue that insurance companies should pick up at least part of the cost since patients need treatment anyway. If the fight isn’t resolved, researchers say it would cripple their ability to conduct clinical trials and significantly slow medical progress. NPR’s Joe Palca reports.

JOE PALCA reporting:

Once cancer of the pancreas has spread to other organs, no known drug can prevent death, but in the mid

The Henry J. Kaiser Family Foundation: The Sex-Ed Divide by Sharon Lerner

The Sex-Ed Divide

by Sharon Lerner

Reprinted with permission of The American ProspectVolume 12, Issue 17. September 24 – October 8 2001

If Maple Grove Senior High chose a prom queen, Ashley Gort would have had a good shot at the crown. Ashley, a petite and popular junior with delicate features, wore deep-sea blue to the event, accessorizing her fully beaded gown with a blue necklace like the one Kate Winslet wore in Titanic and matching blue rhinestones scattered over her pale blond hair. Her boyfriend, Mike Conlin, borrowed his uncle’s Lexus to ferry Ashley to dinner at Landmark Center in St. Paul, Minnesota. Driving away from the restaurant on an unseasonably warm night a few months ago, the couple looked as if they might be headed off for a romantic evening. But while many of their classmates spent the wee hours in rented hot tubs or boogying in Minneapolis clubs, Ashley and Mike drove the half-hour north to a friend’s finished basement in their suburban hometown. With their parents stationed upstairs and peeking in at regular intervals, Ashley, Mike, and a few other couples watched movies, played Ping-Pong, and talked until dawn. They did not drink, smoke, or, as Ashley puts it, “touch each other inappropriately.”

“We couldn’t get like all close with each other,” Ashley explains. Per an agreement they struck with their parents, the kids were allowed to cuddle and hold hands, but physical contact ended there. “Couples weren’t allowed in rooms by themselves,” says Ashley. “There was nothing else you could do, really.”

If such rules sound strange, they don’t to Ashley and many of the other kids enrolled in the Osseo School District’s abstinence-until-marriage class, which teaches students that sex outside of wedlock is physically, emotionally, and spiritually dangerous, while carefully omitting information about birth control, homosexuality, abortion, and other topics that might muddy the message. The curriculum includes sections on “good touch versus bad touch” and refusal skills, and the “Sexuality, Commitment and Family” textbook features a diagram meant to help students figure out exactly where to draw the line (arrows endorse hand-holding and talking, but a red danger sign appears at necking).

While almost a quarter of the nation’s school districts now teach abstinence this way, Osseo schools have earned a page in sex-ed history for offering both of the conflicting approaches to teen sex that have riven the country. Students here can take either the new abstinence class or the traditional course, which both warns kids against sex and prepares them for it with information about condoms and such. For Ashley, the choice was simple: “They talk about gays and lesbians and stuff like that, and I personally don’t want to hear about that,” she says of the older option. “I want to marry the opposite sex. I want to spend my life with that one person and share things with that one person and not other people.”

For Josh Goldberg, a baseball player and good student who is in Ashley’s grade at Maple Grove, the sex-ed decision was also a no-brainer. Josh went for the more explicit of the two health courses. Though some students have taken to calling this the “slutty” class, Josh would hardly fit anyone’s definition of the term. As a sophomore, he counted himself among his school’s “normal people group,” which he translated to mean that he and his friends didn’t drink or go to parties and “there’s a lot of people who are a lot more weird than us.” Indeed, when I met Josh on the first of several visits to Maple Grove, he and his friends seemed to be spending most of their free time jumping up and down on a trampoline in the Goldbergs’ yard and playing with walkie-talkies. (“Come in, Josh. Come in, Josh. You’re going to fail your driving test.” Hysterical laughter.) Still, when it was time to sign up for health–a requirement for graduation–Josh and most of his friends opted for what he calls the “regular class,” while most of Ashley’s friends joined her in taking the abstinence-until-marriage course.

And so it is with students in Osseo’s three senior-high and four junior-high schools: Kids who share Bunsen burners and school colors and class presidents split into two camps to hear two seemingly irreconcilable perspectives on sex. This sorting clearly has something to do with the students’ own feelings about sex. (Of her few friends who didn’t take abstinence class, Ashley worries, “Gosh, I would have thought they would’ve liked to be in this class.”) But the division has even more to do with their parents. Between the two classes and the two adult factions still fighting bitterly over what should go on in the classes, it can sometimes seem as if the national fault line over sex education runs right through Osseo, Minnesota.

It was a snowy morning six years ago when Ashley’s mother, Jeri Gort, felt the first rumblings of Osseo’s war over sex ed. The day started out like any other in the Gort house; Jeri kissed her husband, Randy, good-bye as he headed off to work, wrangled Ashley and her younger sister through breakfast, and then bundled up her daughters and headed out toward the bus stop. When she got there, another mother mentioned that Ashley’s fifth-grade teacher would define sexual intercourse in class that year–and everything shifted for Gort. “At that moment, I truly believe the Holy Spirit came down and made me teary and gave me the grieving of the heart,” she marveled recently. Standing on the corner, watching her daughters and their friends run around in the snow, the innocence of all of Osseo’s children suddenly weighed on her. “I knew then that things needed to change.”

That Jeri Gort would be the one to change things in Osseo was also, as she sees it, a matter of divine intervention. “Most Christian women are soft, but I’m not soft and I’m not sweet. I’m an oddity,” she said recently, as if she were explaining the fact of her blue eyes or her Minnesota-blond hair. “God made me a little rough around the edges. That’s why He spoke to me that day.”

As she stands just five feet tall in white canvas sneakers, with a gentle, Midwestern voice, Gort’s rough edges aren’t immediately apparent. Still, she is the one most people around here credit–or blame, depending on their point of view–for first stoking tensions over the Osseo schools’ approach to sex and then pushing through the district’s Solomonic attempt to resolve them. Starting from that simple bus-stop revelation, Gort managed to create an abstinence class in a school district where most parents didn’t see the need for one and thus set up a road map for conservatives around the country who wanted to do the same.

After hearing about the imminent lesson, Gort decided to “opt” Ashley out of, taking her to lunch on definition day rather than having her exposed to the information. Shortly after, she took herself down to the Osseo District office to review all the sex-education materials and began speaking at parents’ meetings about what she saw there. Not only did sex come up earlier than she would have liked, she reported to parents throughout the district, but the subject was introduced before marriage was. Perhaps most troubling to Gort were the descriptions of different methods of contraception, which she took as an invitation for kids to have sex. “Only half of high-school kids have sex,” she told one group, citing the figure that has become the half-empty glass of sex-education debates. “What about the kids who don’t have sex? What about supporting them?”

Josh Goldberg’s mother, Tobe, one of the parents assembled at that meeting in the Maple Grove Elementary School library, was more concerned with preventing disease and pregnancy in the half of kids who inevitably will have sex. “You can’t have too much information,” the mother of two is fond of saying. “That woman wants to get rid of sex ed,” is what she actually whispered to her husband Arlin that night as they sat squeezed into the child-size chairs in the library. The Goldbergs had already had “the talk” with Josh and his then-10-year-old brother, Noah, making sure that they knew the basics of reproduction and why it’s so important to put it off until later. But Goldberg also wanted her boys to hear about both sex and birth control at school. So when Gort said she was starting a group to reconsider the sex-ed program, Goldberg joined.

Officially, Osseo’s Human Sexuality Curriculum Advisory Committee was just supposed to make recommendations to the school board about how to update sex-education material. In practice, though, monthly meetings were both more intimate and more explosive than that, with Gort leading the committee majority and Goldberg serving as the spokesperson for the much smaller faction that wanted to keep sex ed as it was. The two sides were able to agree on a few things–that pictures of animals with their babies were appropriate for the younger children, for instance, and that fifth-graders were ready to learn about the physical changes that happen in puberty. But on most other issues, people who might have otherwise been exchanging niceties in the supermarket ended up attacking one another’s views on the most personal of questions: Did the clitoris deserve mention in a discussion of female anatomy? Did children need to learn about masturbation? Homosexuality?

Gort suggested that the subject of abortion, which was introduced in eighth grade along with sexual orientation and masturbation, offended some parents and should be removed. In response, another mother muttered something about returning to back-alley days, slammed her eighth-grade textbook shut, and–as others in the dwindling Goldberg camp had already done–stomped out of the sexuality-committee room for good. Committee members also spent months arguing over birth control and the nature of pornography.

As the debate became more specific (several meetings were devoted entirely to the failure rates of condoms), their positions reflected a more fundamental divide. You could see it as political–Goldberg, who eventually became the only person in her camp, was also the only self-described liberal among about two dozen committee regulars. Or you could see the district’s struggle as part of its booming development. The 66-square-mile patch that makes up the Osseo School District used to be potato country, but in the past 20 years, while the number of students in the district has doubled, the area has morphed into the kind of tidy suburb that so many Americans now call home. And as curlicues of manicured streets have unfurled and Babies “R” Us, Barnes and Noble, and Starbucks have sprung into service, some have mourned for Osseo’s rural past. Sexuality-committee chairman Dean Potts seemed nostalgic both for Osseo’s roots and for his own boyhood on a North Dakota farm, where he learned both his conservative values and a certain frankness about sex. (“At grade level four or five, I was personally out pulling lambs out of ewes,” Potts recalled fondly.)

The religious split was even plainer. One of a handful of Jews in Maple Grove and the only Jew on the committee, Tobe Goldberg reached an icy standoff with Potts, who was studying to be a minister in the Church of the Nazarene throughout his tenure as chairman. Another committee member, Tony Hoffman, quoted Scripture when he argued against an educational video that he felt wrongly portrayed gay men with AIDS as victims. And while Goldberg stopped even exchanging pleasantries with her fellow members, a core group of mothers Gort calls the “prayer warriors” was gathering regularly at her house to pray. The prayer warriors prayed for the success of the abstinence class in their cars, while walking, or sometimes even in the hallways and parking lots outside important sexuality-committee meetings.

The prayer warriors were also there when the school board formalized these ideological differences three years ago. Jeri Gort talks of the plan that the board approved by a 3-2 vote as a compromise. But Tobe Goldberg didn’t experience it that way. Not only did the school board create the new two-track health program over her objections; it also approved the committee’s proposal to change the definition of sex that all students would hear. After that board meeting, which stretched until 3 A.M. sexual intercourse was officially no longer an act between any two people but one that occurs between married parents of opposite sex “when the father’s erect penis is inserted into the mother’s vagina.”

On the wall of sex-ed instructor Chris Meisch’s classroom there is a saying spelled out in orange and black construction paper: “No knowledge is more crucial than that of health.” Tacked up nearby are posters addressing why it’s important not to drink and drive and why tobacco is so dangerous. On the first day of the family-life section of Meisch’s third-period abstinence-until-marriage class, there is also a question on the board: “What is love?” Students filtering in after the 9:37 bell obligingly search for an answer. “The feeling you have for people in your family?” one boy asks hopefully. “When you care about someone a lot, even more than you can say?” offers another. When no one comes up with the definition he’s looking for, Meisch, a young, athletic-looking teacher, prompts the 10th and 11th graders, asking them to name different kinds of love. By the time they work their way to “boyfriend-girlfriend love”–past love for parents, pets, and chocolate milk–the point is getting clearer: Love doesn’t always involve sex. “You fall into infatuation,” says Meisch, his tone making it clear that this is not the desired outcome. “You grow into love.” A few students jot this down in their notebooks.

The two versions of high-school health impart many of the same lessons: Drugs are bad for you, exercise good, leafy greens essential. But the abstinence-until-marriage version grapples with the more amorphous questions of values in a way that its counterpart does not. The new course takes the long view, explaining that marriage between a man and a woman has been the norm throughout history and that the only safe sex is “with a marriage partner who is having sex only with you.” Students hear about what makes a compatible mate and even why they should want to mate in the first place. (Parenting, as one abstinence textbook explains, is “a tremendously rewarding commitment based on responsibility and self-sacrifice.”;;) When the subject of birth control comes up, teachers are supposed to discuss only its failures and emphasize its inadequacy.

Students in abstinence class not only hear this particular take on love and romance, they must also present it. Though Ashley did her oral report on tobacco, others whose presentations involved more controversial topics had to cast them carefully in the negative. So when it came time for her report on teens and sexually transmitted diseases, Carol Christensen steered clear of the “good stuff” about birth control that she says she would have mentioned in the other class, trying instead to make a loopy argument that birth control is bad because of its inconvenience. “Like who’s going to go and take out a measuring spoon and measure out the exact spermicide at 1:30 in the morning on a Tuesday night?” she says.

In the interest of preventing such situations, abstinence class offers dating exercises. One homework assignment has students write out their dating standards (extra credit if parents sign them). Another asks, “What do you consider the values of postponing sexual gratification?” Several sections advise on setting limits, though by 10th grade Ashley Gort has figured out many of her own.

“If I know that a person has had a history, or whatever, then I don’t get involved,” she explained to me one afternoon as we sat in “Maple Grove Free,” a family-oriented evangelical church located near the Dairy Queen here. Though she was then “on hold” with the captain of the basketball team, Ashley had never gone long without a date. The key to such lighthearted socializing was to communicate: “You have to make sure you pick the kind of person who feels the way you do; then it’s easier to bring up the subject and everything.”

Her mother’s guidelines also may have helped. Boys were allowed to come by the house and even hang out with Ashley in the family room. (One time, when she was grounded, three stopped by to pay tribute in a single evening.) But per house rules, the family-room door always remained open. And while Jeri trusted Ashley and the Holy Ghost, whom she credited with giving Ashley the desire to stay pure, she was cheered that her daughter’s romances never seemed to last more than a few weeks.

Meanwhile, Josh Goldberg spent his 10th grade more engaged with school and sports than with girls. Still, he felt he had made the right choice about sex ed; abstinence class seemed to leave some teens unprepared. Other students had similar objections to the new class. The Harbinger, the Maple Grove High student paper, weighed in with several articles and a searing, unanimous staff editorial condemning the district, the human-sexuality committee, and the school board for “offering a curriculum of questionable value that is as deceptive as it is bigoted.” The writers took particular offense over the abstinence textbook, which warned against marrying someone of a different economic, cultural, or religious background. When one mother who supports abstinence confronted the Harbinger’s faculty adviser in the school parking lot, tempers flared. She angrily complained that the editorial quoted the abstinence materials out of context, and the adviser, as she tells it, shot back that she was “desperately sad as a fellow Christian that you people have decided to make one of God’s greatest gifts such a shameful and divisive thing.”

The battle that had already torn up the sexuality committee was spreading. Sam Garst, the father of a senior in the district and the retired CEO of a deer-repellant company, founded Osseo Parents for Straight Talk About Sex and printed a brochure with the headline “How Do You Feel About Spending $96,000 More To Educate Our Kids Less?” (The total cost of new abstinence-education materials and arrangements for splitting up students actually ended up closer to $130,000.) Though he got a few positive responses, Garst also received several phone calls informing him that he was going to hell, dozens of angry e-mails (including one accompanied by a computer virus that wiped out his hard drive), and piles of hate letters. “Hey Sammy,” read a typical one. “You go ahead and hand out condoms and pills to your kids, we’ll teach ours right and wrong.”

Meanwhile, across the ideological divide–and a couple of streets–Garst’s neighbor, Scott Brokaw, also felt that he was being attacked for his beliefs. One of two Osseo school board members who championed the new abstinence class, Brokaw says he was wrongly accused of beating his wife by someone who was angry over his position on the sex-ed curriculum. A radio-advertising salesman who calls his opponents “vile and mean-spirited people,” Brokaw ended up hiring a lawyer to defend himself against the charge. On another occasion, when Brokaw and his wife were eating in a local restaurant, a table of teachers and parents opposed to the class sent him a drink that, the waitress informed him, was known as a Blow Job.

For Osseo students, the cost of choosing a side can loom even larger. When he was a junior at Maple Grove High, Andy Caruso went so far as to obtain a waiver of the district’s health-class requirement because he feared the assumptions kids might make about his sex life whichever track he chose. “It seems like a personal thing that you don’t want all your teachers and your friends to know,” he said.

The matter of public perception is, not surprisingly, particularly sticky for girls, who make up the majority of students in Osseo’s abstinence-until-marriage classes. Even in a district with female student-body presidents and girls’ basketball teams that make it to the state finals, girls are still bound by the “hush-hush” rule, as Jessie Sodren, who took the abstinence-until-marriage class, calls it. According to her then-boyfriend, who took the other class, the opposite is true for boys. “Guys just say, like, ‘cool,'” he explains. “They just give each other high fives and stuff.”

Another couple who split up for health class is less candid. “I’ve always known I would save sex for marriage. It’s just the way I was brought up,” says the girl, a 16-year-old sophomore, whose plans for future include “doing something with money, making it grow and making more money.” There would have been no reason to doubt her story had her best friend not mentioned the day before that this same girl had just gone through a terrifying two-and-a-half-month pregnancy scare.

By all student accounts, many sexually active kids end up in the abstinence class–a situation that some attribute to parents who sign them up for it without knowing what’s really going on. “I know the kids that were in there and, like, I know some of them shouldn’t be in there,” explains Josh Goldberg, raising his eyebrows meaningfully. “I don’t think their parents have any idea what’s going on in their life.” Ashley Gort, too, recognizes this. “Some of them, if they do do it, they’re probably not even going to marry the guy,” she told me, shaking her head.

Indeed, students end up in one class as opposed to the other for all sorts of reasons. Carol Christensen took abstinence because the traditional class conflicted with Spanish. Another student, who identifies herself as a born-again Christian and whose mother got pregnant at 16, signed up for abstinence but landed in the traditional class as the result of an administrative error. And one sophomore says she took abstinence because she heard it was easier than the alternative. When I asked her what she hoped to get out of it, she replied, “a C.”

But even kids with the clearest of intentions can’t know what’s in store for them. For Ashley, the surprise came in the form of Mike, the handsome senior with three jobs who, for the past 10 months, has replaced all her other admirers. With a cell phone and her grandfather’s hulking old Cadillac now at her disposal, Ashley can see Mike whenever she’s not doing homework, working at Old Navy, or at dance-line practice.

The Gorts do have a few hard-and-fast rules though: If Ashley doesn’t check in, she loses the car; her weekend curfew is midnight, no exceptions; and when she comes in, she has to kiss her mother goodnight.

“I have a good nose–I can smell pot from a mile away,” says Jeri Gort, who is not above sniffing during this tenderest of evening rituals. “I tell her and her friends, if you start drinking, there’s no way you can be a virgin when you graduate.” Even with all the work she’s done to make sure that her daughter gets the right messages, it still comes down to guarding and worrying for Gort.

The Goldbergs, too, are nervously watching a new relationship blossom. Josh’s girlfriend Janessa first started jumping on the trampoline along with Josh and his friends at the end of sophomore year. Next came cuddling on the couch, long phone calls that Josh sometimes conducted under a blanket if his parents were around, and his crash course in rose buying.

Even though they have already had “the talk,” the Goldbergs find themselves venturing back into that uncomfortable territory lately, reminding Josh about the girl across the street who got pregnant at 16. They’re hoping that their message, along with the instruction he’s gotten in school, will protect their son from all that could go wrong on his way to adulthood.

It’s not terribly different from what’s going on just five minutes away at the Gorts’ house.

Research for this article was supported by a grant from the National Press Foundation and the Kaiser Family Foundation.

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Medicine as a Luxury

by Merrill Goozner

Reprinted with permission of The American ProspectVolume 13, Issue 1. January 1 – 14 2002

It’s generally recognized that people have the right to eat. When famine breaks out, relief agencies rush food to the hungry. Politics and war may get in the way (indeed, they are often the causes of the famine). Sometimes relief efforts are too small or come too late. But the advanced industrial world usually acts as if it has a moral obligation to respond to a hunger crisis.

In recent years, humanitarians have been taking a similar approach to global public health. Shouldn’t we be rushing medicine to people who need it, no matter where they live and no matter how much money they have in their pockets?

Today, microbial plagues are devastating the developing world far more than hunger is. Yet there is no rush to provide assistance. On the contrary, governments and activists have had to force drug companies to help people who are dying simply because they cannot afford the medicine that might save them.

The AIDS pandemic, which has killed 22 million people worldwide and has infected an estimated 36 million (including 26 million in Africa), is only the most notorious of these manageable global killers. According to Doctors without Borders–a group that won the Nobel Prize last year for its tireless efforts to secure medicine for the world’s diseased masses–research and development would go a long way toward fighting tuberculosis, malaria, and leishmaniasis (black fever) as well.

Tuberculosis, largely eliminated in the industrialized world since the 1950s, today infects eight million people a year, 77 percent of whom do not have access to medicine. The result is two million deaths a year, many of which could be avoided with antibiotics that cost less than $100 per course of treatment. Pathogenic resistance to those drugs is growing, however, and few new medicines will kill the most virulent strains of this age-old scourge.

Malaria infects more than 300 million people worldwide every year and kills an estimated one million to two million. Chloroquine, the standard treatment since the 1940s, is increasingly ineffective because of resistance; no new drugs for malaria are in the pipeline.

Leishmaniasis, an immune-system disease that is transmitted by sand flies, has infected more than 12 million people in 88 developing countries. Leishmaniasis-related conditions, including diarrhea and pneumonia, kill more than 500,000 people a year. The standard course of treatment–a derivative of the heavy metal antimony–costs $150 and has nasty side effects. As with malaria, no new drugs have been developed to combat this disease since the 1930s.

The escalating campaign to force the global pharmaceutical industry to provide affordable medicines to fight these plagues took another step forward this November in Doha, Qatar, where the World Trade Organization met to launch the next round of trade negotiations. A coalition of more than 80 developing nations and nongovernmental organizations (NGOs) pushed the WTO to reaffirm language that already exists in its charter. Every nation has the right to void patent laws and grant licenses to generic manufacturers of essential medicines in order to meet public-health emergencies, the resolution read. U.S. Trade Representative Robert Zoellick, whose office usually acts on the industry’s behalf when faced with intellectual-property issues, opposed the language until the last moment. The Clinton administration, with similar priorities, threatened trade sanctions against South Africa after it passed an essential-medicines licensing law in 1997. The Bush administration did the same until April of this year, when 39 multinational drug companies finally dropped their suit against the law.

In the weeks leading up to Doha, the United States and Switzerland did everything they could to water down the resolution that supports compulsory licensing to meet public-health emergencies. They backed down only when it appeared that the issue might doom the Doha talks.

Listening to Cipro

By the time Doha rolled around, Big Pharma and its allies in the U.S. government were already on shaky ground because of the anthrax crisis. As the government scrambled to acquire an adequate supply of antibiotics to treat a worst-case bioterrorist attack, the Department of Health and Human Services asked Bayer AG, maker of ciprofloxacin (the one anti-anthrax drug that is still on patent), to give the government a special deal. Those negotiations revealed to anyone paying attention–and that included virtually every health and trade minister in the developing world–that the global pharmaceutical industry and its U.S. government allies were more concerned with protecting pill patents than with providing affordable medicine to meet a crisis.

Within a week of NBC anchor and terror target Tom Brokaw’s on-air declaration “In Cipro we trust,” Health and Human Services Secretary Tommy Thompson, the glad-handing former Wisconsin governor best known for cracking down on his state’s welfare mothers, began sounding like the minister in charge of Canada’s national health service. He threatened to void Bayer’s patent for Cipro unless it delivered up to 300 million tablets at cut-rate prices. Senator Charles Schumer of New York and Congressman Sherrod Brown of Ohio introduced legislation that would have compelled the administration to seize Bayer’s patent for generic production.

Thompson, feeling the heat, told Bayer to get out its sharp pencils and cut the United States a better deal. At a hastily arranged meeting in Washington, the company delivered–but at twice the generic price. Three generic makers said they could make Cipro for 40 cents a pill, less than one-tenth of the pre-September 11 average wholesale price–though their hands were hardly clean either: Generic manufacturers have accepted more than $200 million from Bayer over the past several years not to make Cipro. This arrangement, a common drug-industry practice, is under investigation by the Federal Trade Commission. Trying to rein in its galloping public-relations fiasco, Bayer ran dozens of full-page ads in the nation’s leading papers as it sought to reassure Americans that the company stood by them.

Even the deal to purchase cut-rate Cipro was dubious public policy. Thompson’s big purchase also ignored the fact that there were far cheaper alternatives, like generic doxycycline, that treat anthrax as well as Cipro does. The government’s rush to stockpile Cipro ignored the potent antibiotic’s serious side effects, which can include nausea, diarrhea, and potentially crippling damage to the cartilage of weight-bearing joints. The high-profile move encouraged doctors to write prophylactic prescriptions, thus ignoring the warnings of the government’s own public-health experts that the drug’s overuse might breed superbugs resistant to all strains of antibiotics.

By the time public-health officials had stuffed the cotton back into the Cipro bottle, developing-world health ministers, NGO activists, and generic-drug manufacturers were having a public-relations field day. Weren’t Thompson’s efforts to negotiate lower prices precisely what they’d been trying to do for years–open up access to affordable HIV/AIDS medications? Hadn’t the drug industry and the U.S. government consistently thrown up legal roadblocks to their efforts? Editorials supporting the Doha resolution popped up in almost every major U.S. newspaper. “Americans today can surely understand the need to give poor countries every possible weapon to fight back,” said The New York Times.

It’s unfortunate that it took an anthrax-bioterrorism crisis for the majority of Americans to finally get it. Only in the past year have organizations like Doctors without Borders, the Consumer Project on Technology, and the United Nations’ agency UNAIDS succeeded in convincing the drug industry’s giants to sell AIDS medicines at reduced prices.

And why have the drug companies finally come around? Mounting media scrutiny of the affordable-AIDS-medicines issue surely played a part. But in the end, industry leaders voluntarily established cheap-treatment programs to avoid what in their eyes was a worse fate: widespread adoption of the Brazilian precedent.

Free Trade, Free Drug Production

In Brazil, health authorities have one of the best records in the developing world when it comes to providing drugs for their HIV-positive population. They’ve used existing international trade law to issue compulsory licenses to generic-drug manufacturers for the production of inexpensive AIDS drugs. And when they haven’t contracted with generic manufacturers directly, they’ve threatened to do so in order to wrest lower prices from global pharmaceutical firms. Last August, Swiss-based Roche reduced the price of the AIDS drug nelfinavir to 30 percent of its U.S. wholesale price after the Brazilian health ministry threatened to seize the patent and award it to a state-owned manufacturer.

According to many activists, the Doha resolution didn’t go far enough. The TRIPS agreement, the WTO’s protocol governing trade-related aspects of intellectual property, still prohibits consumers from directly buying so-called parallel imports, which are cheaper generics from countries with low-cost production facilities. Many developing countries don’t have the manufacturing capacity to produce complex chemicals like pharmaceuticals. A reasonable parallel-import clause would allow health officials in one country to ask a generic manufacturer in another to produce the critical medicines it needs to meet a national health emergency.

Despite the limited nature of the Doha resolution, Big Pharma reacted to the setback with the usual complaints. Allowing generic manufacturers in developing countries to produce branded products would lead to first-world gray markets. The wily generic makers in India, Brazil, and South Africa would inevitably export their low-cost medicines to Europe, the United States, and Japan at prices far below the first-world patent holders’ rates. Only by maintaining high prices for medicines would industry have sufficient incentive to come up with new cures for disease. Indeed, medical progress itself depends on maintaining the sanctity of the global patent system. “This is a defeat for drug companies doing research in AIDS, tuberculosis, and the like,” said Harvey Bale, a lobbyist for the International Federation of Pharmaceutical Manufacturers Associations.

Again, the Cipro case effectively debunked those claims. Ciprofloxacin, Bayer’s best-selling drug, is the top-selling antibiotic in the world. It generated over $1.6 billion in sales last year, largely because it sold wholesale for $4.67 a pill. Since generic manufacturers can make the drug for a tenth of that price, Bayer no doubt was already earning enough from the markup to fund its R-and-D labs, cover its marketing costs, and still make money. So when the anthrax attack triggered unanticipated demand from the U.S. and Canadian governments, any price set at more than production costs would have represented pure profit to the firm.

Drugs for HIV-infected patients around the world follow a similar dynamic. Pharmaceutical companies set their prices for AIDS drugs based on first-world market conditions. A decade ago, there was a huge uproar over the price of the initial AIDS drugs, which were largely the product of government research and licensed to Glaxo Wellcome–now GlaxoSmithKline–and Bristol-Myers Squibb. Those complaints died down once insurance companies and government agencies began picking up the tab. We certainly don’t hear many complaints these days from the drug companies, although they occasionally grouse that profits on AIDS drugs have not been as high as they had hoped.

The third world’s desperate need for AIDS drugs can be compared to the Cipro affair in that it represents a form of unanticipated demand. Most of the 30 million people in developing countries who have the disease can spare little or no money to pay for drugs. And where there’s no money, there’s no market. Their governments can make a market, but only by spending scarce public-health funds. (Only recently have many governments, especially in Africa, been willing to take that step.) Buying those drugs at the marginal cost of production would not change the underlying research incentives for industry.

Indeed, if the global South’s poor were the only people in the world who were HIV-positive, there would be no industry R and D aimed at AIDS, just as there has been precious little R and D–and virtually no new drugs–for tuberculosis, malaria, and leishmaniasis. A recent Doctors without Borders survey of the world’s 11 largest pharmaceutical firms found that of the 1,393 new drugs introduced over the past quarter-century, only 13 were aimed at tropical diseases.

Governments are the only parties that can fill the public-health gap. Bioterrorism again provides a convenient example. A few weeks into the anthrax crisis, several leading industry players called on the government to treat them like defense contractors by giving out “cost-plus” contracts for research and development of new antibiotics to counter germ-warfare agents. Given the uncertainty about the size of the market and the demonstrated government concern about price, they said, it would be the only way to keep the industry’s hand in the game.

Cost-plus R-and-D contracts to produce drugs for diseases that have no market? Now there’s a thought. But why stop at bioterrorism agents? Why not malaria? Why not tuberculosis? And why not allow public-sector labs to compete with the industry labs for those contracts, so the patents could stay in the public domain? Any drugs that came out of such government-funded research should be treated as a social good, both domestically and globally, and broadly distributed based on need. Such a government-funded program might even lessen anti-American hostility in the developing world.

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