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Tue Apr 4 14:18:10 1995
III.
Erroneous Claims Denials For IDPN Therapy
Despite the clear coverage of IDPN therapy under HCFA's Manuals and the DMERC
Supplier Manual, since the transition to DMERCs, virtually all claims for IDPN therapy for
nongrandfathered patients have been denied. 1 The problems appear to fall into seven major areas,
summarized below. Specific sample and fair hearing decisions illustrating these problems are attached
as exhibits.
A. Inappropriate Denials Based On "Supplementation"
Many IDPN claims have been denied on the ground that the therapy only provides a
certain percentage of the patient's daily caloric intake and is, therefore, supplemental in nature 2 We
submit that these denials reflect a fundamental misunderstanding of IDPN and the prosthetic device
benefit.
Enteral supplements (such as Ensure, Isocal, and Nepro) consumed orally have never
been covered under the Medicare program and have been stated to be supplemental.³ These products
are given in between or in conjunction with meals for the purpose of bolstering the patient's total calorie
intake, not to provide the patient with the nutrients necessary to maintain reasonable weight and strength
commensurate with the patient's overall medical condition. DMERC officials have recently extrapolated
this same rationale to apply to any form of "supplementation." whether it is enteral or parenteral. As
1
The Region C DMERC paid claims for IDPN for a few months during the transition from local
to regional carriers. Since approximately October 1994, all claims submitted to the Region C
DMERC for nongrandfathered claims have been denied as well.
2
Sample review letters and fair hearing decisions are attached at Tab A; see also decision attached
at Tab J.
3
See, e.g., HCFA-Pub. 6, § 65-10.3 (nutritional supplementation to boost protein-calorie intake
not covered under Medicare Part B); PEN Manual at p. 6 (nutritional supplementation given in
addition to usual daily diets not covered under Medicare Part B).
previously stated, however, neither the Act, the HCFA Manuals nor the DMERC Supplier Manual
preclude coverage of intravenous nutrition on this basis.
Under the prosthetic device benefit, parenteral nutrition therapy is covered when it
replaces all or part of a missing or malfunctioning missing internal body organ. Further, these
provisions as well as the DMERC Supplier Manual itself -- state that the degree of malfunction needed
to qualify must be such that the patient is not able to absorb sufficient consumed nutrients to maintain
reasonable weight and strength commensurate with the patient's overall medical condition. It is quite
clear from the language of the statute, as well as the HCFA manuals, that IDPN is a covered benefit
when the patient suffers from a significant gastrointestinal malfunction which prevents absorption of
sufficient nutrients to maintain the patient's health status. Just as a leg prosthesis is covered for a below
knee amputation, and a cardiac pacemaker is covered for a conduction disturbance of the heart,
parenteral nutrition is covered for patients who have partial but significant malfunctioning of their
gastrointestinal tract if the malfunction results in clinically significant malnutrition- and cannot be
feasibly overcome with consumed food. In other words, nutritional depletion is not an all or nothing
determination.
DMERC claims processors have informed our members that any claim for parenteral
nutrition to be administered less than daily is not covered. Again, there is no requirement under the
Medicare coverage provisions that parenteral nutrition be administered daily. Indeed, the DMERCs'
own written medical policies state that claims for parenteral nutrition ordered less than daily are to
include documentation supporting the need for the therapy, as set forth above.
We understand that HCFA has recently clarified in comments to the DMERCs that
coverage under the prosthetic device benefit can be total or partial. The patient need not rely upon
either enteral or parenteral nutrition for his or her total nutrition in order to be eligible for PEN therapy.
As long as the patient has a dysfunction of the gastrointestinal tract with accompanying malabsorption
- 2 -
such that the patient is unable to maintain weight and strength commensurate with the patient's general
condition, coverage is indicated. Because this clarification is simply a restatement of current coverage
policy, we submit that the claims denials on the basis of "supplementation" must be reversed. and all
claims must be paid.
B.
Incorrect Application Of Total Parenteral Nutrition Requirements To IDPN Claims
In many cases, the DMERCs have inappropriately applied the requirement with respect
to TPN of 20-35 cal/kg/day to claims for IDPN.4 Under the DMERC medical policies, these rules are
only applicable to coverage for total parenteral nutrition. As noted, TPN is usually contraindicated for a
renal patient due to the requirement for a surgical incision to place a subclavian catheter, increasing
infection complications and potential fluid and electrolyte overload. Therefore, claims denials on this
basis are invalid.
C.
Denial Of Claims Based On Absence Of Tests Or Procedures That Are Not Required
Under The DMERC Medical Policy
Another basis for denying IDPN claims is that the claim submitted reportedly lacked
information that tube feeding had been tried and failed. 5 As noted, there is no requirement in the
Medicare Coverage Issues Manual, the Medicare Carriers Manual or any of the DMERC Supplier
Manuals that g-tube feeding be tried prior to coverage of IDPN therapy. There are sound clinical
reasons for not requiring such tube feeding, as discussed previously in Section I. Further, in responding
to comments on the draft medical policies, the DMERCs specifically said that coverage should not be
required to be established based on extraordinary tests or procedures not part of normal medical care of
4
Sample review letters and fair hearing decisions are attached at Tab B. We note that two of the
review letters also inaccurately refer to the claim for IDPN as "enteral supplies."
5
Sample fair hearing decision is attached at Tab C. This issue is also discussed in several of the
decisions attached at Tab A and B.
- 3 -
the patient. In response to a comment that the written guidelines for enteral and parenteral nutrition
required documenting "unfavorable events," the DMERCs respond:
It is not the intent to subject patients to a "challenge" of a covered
formula just to obtain documentation of an advanced adverse reaction. If
the patient's records indicate known, or a likely, untoward reaction to a
therapy, this documentation alone meets the test of medical necessity. 6
Contrary to their own written policies, the DMERCs are apparently attempting to require nephrologists
and other clinicians to subject already severely compromised patients to yet another surgical procedure,
creating an increased risk of infection and accompany cardiac and pulmonary malfunction. It is well
settled that carriers are required to follow their own standards in adjudicating claims. 7 In this case,
there is absolutely no basis for requiring tube enteral feeding prior to coverage of IDPN.
D. Denials Based On Inaccurate Clinical Conclusions
Several of the fair hearing decisions have upheld claims denials based on inaccurate
clinical statements. For example, in one hearing decision, the hearing officer (not a physician)
concluded that "gastroparesis is an upper GI diagnosis and does not represent an absorption problem of
the GI tract. "8 No authority is cited for this proposition, and, in fact, it is blatantly wrong.
Gastroparesis is the paralysis of the stomach. Dorland's Illustrated Medical Dictionary, 26th ed. (1981).
This condition hampers ingestion and compromises absorption of nutrients. Essentially, the patient
experiences diarrhea and vomiting and is not able to ingest, let alone absorb, nutrition.
6
See Region A comments and responses to draft medical policy on enteral and parenteral
nutrition, comment 4 (Section II, Tab G) (emphasis added). Similar comments were
issued by each of the DMERCs.
7
See, e.g., Morton V. Ruiz, 415 U.S. 199 (1974).
8
Copy attached at Tab D.
- 4 -
Other fair hearing officers have upheld denials on the grounds that the evidence
documented no "permanent absorption defect of the small intestine. "9 Again. there is absolutely no
requirement in the HCFA Manuals, nor in the DMERC Supplier Manuals, that the patient evidence a
defect of the small intestine. Rather, as noted, the requirement for coverage is a problem with
absorption of nutrients due to a disease or malfunction of the gastrointestinal tract. In addition, some
fair hearing officers have upheld claims denials on the ground that no fecal fat test or other test used to
document malabsorption had been submitted. 10 First, there is no requirement to conduct a fecal fat test
on patients prior to coverage. While fecal fat has been used to help verify malabsorption, it is difficult
to obtain patient cooperation. Second, lower albumin levels and protein levels are tests used to
document malabsorption which accompany every claim for IDPN therapy. As noted, lower albumin
levels are a regular and reliable measure of malnutrition in renal patients. Therefore, denials based on
the absence of a fecal fat study are completely without merit.
E. Inappropriate Denials For Additional Information
-
Numerous claims submitted by IDPN suppliers have been improperly denied for an
alleged lack of information. Our review shows, however, that such claims have generally included
extensive documentation supporting the physician's order. When asked to specify what additional
information is required, carrier staff are often unwilling or unable to specify what is needed.
F.
Inexperienced And Inadequate Provider Relations/Medical Review Staff
The DMERC medical review staff charged with adjudicating claims for IDPN therapy
appears to have inadequate experience to conduct consistent, comprehensive reviews, for this therapy.
We understand that some specialists in renal nutrition have met with DMERC staff about IDPN therapy,
9
Copies of sample decisions are attached at Tab E.
10
Sample fair hearing decision attached at Tab F.
- 5 -
but these efforts have not proved successful in addressing common misconceptions about IDPN, as
discussed above.
In addition, the DMERCs' medical review staff have refused to explain medical review
criteria and have denied claims for nongrandfathered patients while approving claims for grandfathered
patients with virtually identical diagnoses and medical conditions. 11 Further, the staff appear
predisposed to deny all claims for IDPN, regardless of the patient's condition. For example, DMERC
claims review personnel have told our members that "we do not pay for this service," and that "claims
for IDPN will be denied." These statements are clearly inconsistent with HCFA and DMERC policy
that covers IDPN therapy for beneficiaries meeting applicable medical necessity criteria.
As you know, one of the purposes of regional claims processing for DMEPOS was to
consolidate carrier personnel knowledgeable about these items in specialized carriers. This was the
reason for establishing the PEN specialty carriers which, in fact, achieved such expertise and relatively
smooth claims processing for suppliers and carriers alike. The DMERC's inability or refusal to provide
this level of expertise is deeply troubling and, in fact, undermines the whole purpose of providing
regionalized specialty carriers.
G.
Extensive Delays In Carrier Claims Processing And Lack Of Independent Review At Fair
Hearings
Beyond these substantive errors in medical review, the DMERC claims processing of
claims for IDPN therapy has been exceedingly slow, with DMERCs failing to issue reconsideration
decisions for several months following the initial denial. Moreover, we have significant concerns that
the DMERCs are not providing fair hearings in accordance with the provisions set forth in the Medicare
Carriers Manual regarding the appeals process.
11
Samples of fair hearing decisions issued prior to the transition to DMERCs in which
coverage has been upheld are attached at Tab G.
- 6 -
Pursuant to Section 1842(b)(3)(C) of the Act, carriers are required to establish and
maintain hearing procedures for individuals dissatisfied with payment determinations. 42 U.S.C.
§ 1395(u)(b)(3)(C). The Medicare Carriers Manual provides that the purpose of the hearing is to allow
the dissatisfied beneficiary or supplier (in the case of assigned claims) an opportunity to present the
reasons for dissatisfaction with the determination and to receive a new determination based on the record
developed at the hearing. The hearing officer is required to be an individual who "has not been involved
in any way" with the determination in question. HCFA Pub. 14-3, § 12016.B. Moreover, ex parte
contact by the hearing officer is specifically forbidden. Id. A hearing officer is disqualified if the
individual was involved in any way in the initial or review determination. Id. at § 12016.C.
Due to the significant delays in processing the claims for IDPN therapy and for issuing
review determinations, few claims denials have reached the fair hearing level. For example, of the
1.308 claims for nongrandfathered patients submitted by one member of the Coalition, only 32 (2%)
have been reviewed at fair hearings and only two have been scheduled for an administrative law judge
("ALJ") hearing. Nonetheless, of those claims for which a fair hearing has been held, the hearing
officers have routinely relied on the DMERC medical director for input on the claims decision. For
example, one fair hearing decision states, "upon recommendations from the DMERC Medical Director.
Adrian Oleck, M.D., I find that the evidence in this case lacks significant documentation to establish
medical necessity for the parenteral nutrition therapy. 12 In another, the hearing officer states that "the
opinion of the Medical Director [of Region A] has been given due consideration along with the medical
documentation presented. 13 Because the medical director is generally responsible for the initial claim
denial and the review determination of the claim for IDPN therapy, the fair hearing does not result in an
12
Copy attached at Tab F.
13
Copy attached at Tab H.
- 7 -
independent review of the determination. Further, such ex parte contacts with the medical director are
explicitly forbidden.
In addition, several of the hearing officers' decisions are simply form letters in which
the name of the provider and the beneficiary are changed. Indeed, members of the Coalition have noted
that some hearing officer decisions contained exactly the same language - including the same
grammatical and typographical errors - despite the fact that the beneficiaries have very different clinical
conditions. 14
Finally, several of the decisions issued by hearing officers contain blatantly incorrect
statements of Medicare law. For example, one fair hearing officer decision refers to Section 1862(a)(1)
of the Act as relating to inherent reasonableness. The hearing officer's decision states:
Furthermore, inherent reasonableness under Section 1862(a)(1) of Title
XVIII states that it is more reasonable to pay for a less costly alternative
unless the more costly method has been tried and failed. 15
As you are well aware, Section 1862(a)(1) of the Act has nothing to do with inherent reasonableness, let
alone any mention of less costly alternatives. Rather, this section pertains to the general Medicare
requirement that items and services be "reasonable and necessary for the diagnosis or treatment of
illness or injury or to improve the functioning of a malformed body member." Section 1862(a)(1)(A) of
the Act, 42 U.S.C. § 1395y(a)(1)(A). IDPN therapy provided to beneficiaries meeting the medical
necessity criteria established in the Coverage Issues Manual is clearly reasonable and necessary for the
diagnosis or treatment of illness or to improve the functioning of a malformed body member (i.e., the
nonfunction of the gastrointestinal tract). Such clear misstatements of the Medicare law and the absence
14
Two examples of such form decisions are attached at Tabs D and I, respectively.
15
Copy attached at Tab J.
- 8 -
of independent review determination significantly undermine the purported value of the DMERC's
appeals process for denied claims.
In sum, the DMERCs' IDPN claims denials, and the approval of those denials upon
reconsideration and at the fair hearing level, show a concerted, systematic effort to deny coverage for
IDPN therapy without regard to the patient's underlying medical condition or established Medicare
coverage policy. Contrary to the well-established Medicare coverage criteria for IDPN therapy and the
DMERCs' own written medical policies, the DMERCs have established barriers to IDPN
coverage - through front-end claims edits, unnecessary and clinically contraindicated additional
requirements, and essentially form fair hearing decisions. This situation has resulted in virtually
universal denial of Medicare coverage for IDPN therapy.
-
- 9 -
Malnutrition in the Dialysis Patient*
Malnutrition is recognized to be a primary determinant of increased morbidity and
mortality in ESRD patients [1,2,3,4,5]. The National Cooperative Dialysis Study [NCDS] was
one of the first large scale studies to indicate that protein malnutrition, identified by a low
protein catabolic rate, was second only to inadequate dialysis in predicting poor outcomes for
dialysis patients [2]. The U.S.Renal Data Systems [USRDS] also indicated that low serum
albumin was a major predictor of mortality in new dialysis patients [6,7].
Consistent with these findings, Lowrie et al [5] reported results of an extensive
retrospective study of the effect of hypoalbuminemia on mortality in dialysis patients. They
demonstrated that serum albumin was the most important laboratory predictor for death in this
patient population. In this study, as serum albumin declined, the mortality rate dramatically
increased. For patients whose serum albumin ranged between 3.0 - 3.5 gm/dl their mortality
increased five fold. Mortality at one year of dialysis for patients with a serum albumin
between 2.0 - 2.5 gm/dl approached 100 per cent in this study.
Dialysis patients are predisposed to developing malnutrition due to many contributing
factors. These include: metabolic changes [such as altered protein metabolism, carbohydrate
intolerance and nutrient loss during dialysis]; inadequate dietary intake due to dietary
restrictions, nausea and vomiting; interactions between medications and food; and blood loss.
In addition, the dialysis procedure is considered to be a catabolic procedure causing
endogenous release of cytokines with subsequent increased protein breakdown, and loss of
amino acids across the dialyzer [8,9]. Severe cachexia often exacerbates the problem as
uremia and concurrent disease can frequently induce abnormalities of the intestinal mucosa
and also impair appetite.
While these abnormalities clearly add to the obstacle of providing adequate nutrition to
the dialysis patient, they are especially significant for those patients who also develop a
concurrent chronic disease which results in partial to complete malabsorption. When this
clinical circumstance develops, it is generally impossible for the patient to maintain weight
and strength through oral nutrition intake even when such nutrition is fortified with nutritional
supplementation.
* Arthur R. Olshan, M.D., Ph.D., Richard Dowling, R.Ph., and
Karen Basinger, M.S., L.N., Prepared This Clinical Summary.
A.
Partial Gastrointestinal Malfunction
Gastroenterologists and nutritional support specialists recognize the clinical
concept that there are a substantial number of disease entities that result in partial, albeit
clinically significant gastrointestinal malfunction. This malfunction is clinically important
when it is of sufficient severity to prevent an individual from being able to absorb enough
from consuming caloric dense foods to sustain or achieve desired weight and strength.
Examples of such diseases include:
- diabetic gastrointestinal neuropathy and enteropathy
- ischemic vascular disease of the intestine
- chronic pancreatitis
- uremic autonomic dysfunction
- inflammatory bowel disease [Crohn's]
- radiation enteritis
- short bowel syndrome
- intestinal obstruction
It is also generally accepted that these diseases may result in the need to
provide 50 - 80 grams of protein in 1000 - 2000 kcal of parenteral nutrition three or four
times per week with the clinical goal of bridging the caloric and protein gap created by the
patient's gut failure. The most appropriate therapeutic modality for these patients would be
one that could provide sufficient total protein and calories to meet the protein/calorie deficit
while introducing the least amount of added risk to the patient. It has been estimated that
approximately four per cent of the dialysis population will develop one of the aforementioned
conditions resulting in substantial gut failure at some point in their life [unpublished data
from Lowrie, surveying 56,139 ESRD patients].
B.
Treatment Options
1. Enteral Supplementation
Enteral nutritional support is the preferred mode of repletion in most patients.
As such, this route is always the first approach and is often successful in achieving the
desired outcome. Every dialysis center in the United States has a renal dietician experienced
in treating the nutritional needs of dialysis patients. In addition, nephrologists are generally
aware of the interplay between dialysis and nutrition. As such, it must be recognized that
exhaustive attempts to help the patient improve his or her nutritional status through aggressive
dietary counseling and the use of oral nutritional supplements is routinely done. However,
when substantial malfunction of the gastrointestinal tract exists, adequate oral intake will be
impossible to achieve in this group of patients. When dietary counseling, adequate dialysis,
and enteral nutrition cannot overcome severe gastrointestinal malfunction, another form of
nutrition support therapy is generally necessary.
-2-
2. Tube Feedings
Daily tube feeding should be considered whenever the patient's gastrointestinal
function is limited by the inability to swallow oral nutrition. However, daily tube feedings
often are contraindicated in the dialysis patient population. Because these patients frequently
have upper gastrointestinal motility abnormalities characterized as gastroparesis, prepyloric
feeding [gastrotomy] may induce vomiting and possible aspiration pneumonia. Gastrostomy
tubes placed across the pylorus into the small bowel render the pylorus incompetent and still
subject the patient to the risk of aspiration pneumonia. Further, postpyloric feedings via a
surgically placed jejunostomy tube represents an invasive procedure with increased morbidity
in a malnourished dialysis patient which should only be considered when the patient's
gastrointestinal abnormality is limited to a swallowing disorder. ESRD patients also have
unique problems handling fluid loads. Tube feedings can cause unacceptable problems with
recurrent congestive heart failure in this patient population. Additionally, and equally
important, the use of either a nasogastric tube or a surgical feeding tube is psychologically
and emotionally unacceptable to many of these ambulatory dialysis patients who can continue
to lead a reasonably active life.
3. Daily Total Parenteral Nutrition
After all reasonable enteral methods of treating malnutrition in dialysis patients
have either failed or been clinically ruled out, total parenteral nutrition (TPN) therapy can be
a potentially lifesaving alternative. Daily TPN therapy can provide all of the nutrients needed
to sustain a patient's health and well being. Because nutrients are administered directly into
the patient's central venous circulation via an indwelling catheter, this method of treatment
effectively circumvents the patient's malfunctioning gastrointestinal tract, allowing the patient
to sustain weight and strength. Use of this therapy option should be considered when the
patient's gastrointestinal disease results in a caloric deficit which can only be overcome by
this approach.
However, daily TPN also has inherent risks, some particularly significant to the
renal failure patient. In many cases, the risks of this therapy diminish the potential value of
this treatment. These risks may be mechanical, infectious, cardiac or metabolic. Home TPN
requires the surgical placement of a subcutaneously tunneled silicone or polyurethane catheter.
Such catheters may damage central veins causing venous thrombosis or stenosis, jeopardizing
the patient's current dialysis access and rendering that entire side of the patient unavailable for
any new dialysis access creation. The latter is a particularly unacceptable complication, as
the vascular access is the individual's lifeline needed for hemodialysis therapy.
Infectious complications, including blood-borne septicemia, are a particular
concern in the uremic immuno-compromised state. Many dialysis patients are skin carriers of
potential pathogens for infection, especially Staph aureus [10]. Many of the life threatening
infections encountered by dialysis patients result from bacterial colonization of the
arteriovenous fistula or graft. Use of an external catheter, as would be needed for daily
parenteral nutrition, can be expected to have an even greater potential for infection.
-3-
Fluid overload and electrolyte abnormalities are the most commonly
encountered severe complications of daily TPN. Since ESRD patients cannot eliminate the
infused fluid between dialysis treatments, they may develop congestive heart failure or acute
pulmonary edema. Hyperglycemia and electrolyte abnormalities are some of the metabolic
complications of daily TPN.
In summary, daily TPN clearly will increase the risk of sepsis, threaten the
viability of the patient's current and future dialysis access sites, and expose the patient to
potentially lethal cardiac complications, and fluid and electrolyte abnormalities.
4. Intradialytic Parenteral Nutrition [IDPN]
IDPN has been employed over the past ten years for malnourished
hemodialysis patients who had failed attempts at dietary and pharmacologic management,
including enteral supplements. IDPN is administered during the dialysis procedure, through
the patient's vascular access, which obviates many of the problems associated with daily TPN.
The risks of vascular thrombosis and sepsis posed by a central TPN catheter are eliminated,
and the dialysis procedure removes the excess fluids, minimizing the likelihood of congestive
heart failure.
One IDPN treatment can provide 60 - 75 grams of intravenous protein, or an
average of 1 - 1.4 grams per Kg per treatment. It also provides approximately 1100 total
calories per treatment of 3300 calories per week, which is sufficient to overcome the caloric
deficit of most patients with clinically significant malfunction of their gastrointestinal tract.
Multiple studies document that IDPN, in appropriately selected patients,
promotes weight gain, increases functional status, improves serum albumin and improves
survival in malnourished dialysis patients [11, 12, 13, 14, 15, 16]. Olshan et al [11]
administered IDPN to ten patients who had failed six months of dietary counseling and
enteral supplements. The patients had lost an average of 13 per cent of their usual body
weight and were at 88.6 per cent of ideal body weight at the start of IDPN. After two
months of IDPN, the patients gained weight, improved their functional status and had a
significant increase in their serum albumin. Bilbrey et al [12] from a population of 204 long
term dialysis patients, identified 20 patients with moderate to severe malnutrition. After 3
months of IDPN, these patients had a significant improvement in their baseline malnutrition
index. Cano et al [13] in a controlled study, administered IDPN in a random fashion to 12 of
26 malnourished dialysis patients. Compared to control patients, IDPN patients showed
significant improvement in body weight, arm-muscle circumference, serum albumin and skin
test reactivity. Foulks et al [14] described reduced mortality and hospitalization rate in a
selected subset of malnourished ESRD patients that were IDPN "responders".
Capelli et al [15] identified 81 ESRD patients with depressed albumin levels
[<3.5 gm/dl] and a body weight at least 10 per cent below ideal body weight or a loss of 10
-4-
per cent of their usual body weight over two months. All the patients had previously
received nutritional counseling by certified dieticians, and dialysis to ensure KT/V of 1 to 1.2
or greater. 50 patients received IDPN and 31 did not for an average length of treatment of 9
months. Using the Cox proportional hazards survival analysis, a significantly increased
survival rate was observed with the use of IDPN [relative risk = 1.34,p<0.01]. No other
covariant followed [age, diabetes, weight, change in weight, albumin, KT/V, protein catabolic
rate, length of time on dialysis, sex, race] significantly affected survival rate.
Chertow et al [16] analyzed data on 24,196 ESRD patients on dialysis during
1991. 22,517 patients who received dialysis on 1/1/91 and were still on dialysis or who had
died by 12/31/91 served as controls. The IDPN treatment sample consisted of 1,679 patients
who received one or more infusions of IDPN during 1991. Control and IDPN patients were
analyzed for age, sex, race, presence of diabetes, baseline renal diagnosis, urea reduction
ration [URR], and serum concentrations of albumin and creatinine. Survival in the two
groups were then compared. Initial analysis indicated that patients treated with IDPN were
older [p<0.01] than controls, and were more likely to be white or diabetic [p<0.01]. At the
start of therapy, serum albumin and creatinine were also significantly lower among IDPN
treated patients compared to controls [p<0.01].
An analysis of the odds ratio of death at different serum albumin levels
indicated significantly improved survival in the IDPN group at all albumins ≤3.3gm/dl.
Odds Ratio of Death
Comparing IDPN Treatment
Serum albumin (gm/dl)
Group With Controls
P Value
≤ 3.4
0.87
P<0.10 (NS)
≤ 3.3
0.73
P<0.01
≤ 3.2
0.62
P<0.01
≤ 3.1
0.62
P<0.01
≤ 3.0
0.58
P<0.01
The improved survival of IDPN treated patients also approached significance at
serum albumin <3.4 gm/dl [p<0.1]. This was despite the fact that both controls and IDPN
patients had equivalent dialysis [URR>60 per cent]. The improved survival with IDPN in
patients with albumin ≤3.4 gm/dl became even more significant in patients with a
concomitant creatinine <8.0 mg/dl, a sign of of somatic protein depletion. Time trends for
serum albumin and creatinine showed progressive decline in these parameters pre IDPN.
-5-
However, patients started on IDPN with pre-treatment serum albumins <3.4 gm/dl showed a
progressive increase in serum albumin and creatinine over the 12 month study period. The
analyzed data showed a survival disadvantage when IDPN was administered to patients with a
serum albumin >3.5 m/dl, particularly in association with a serum creatinine >8.0 gm/dl. Thus
IDPN is not appropriate for dialysis patients "failing" for circumstances other than
nutritional failure.
In summary, this study, involving large numbers of dialysis patients carefully
followed for one year, indicate that IDPN can be life saving when administered to
appropriately selected, malnourished dialysis patients. Signs of visceral protein depletion
[serum albumin ≤3.4 gm/dl], and to a lesser extent signs of somatic protein depletion [serum
creatinine <8.0 mg/dl] identified dialysis patients that would have improved one year
survivals if given infusions of IDPN.
-6-
REFERENCES
1. Acchiardo, S.R., Moore, L.W. & Burk, L., Morbidity and Mortality in
Hemodialysis Patients, ASAIO Transactions, 36: M148-151 (1990).
2. Acchiardo, S.R., Moore, L.W., & Latour, P.A., Malnutrition as the Main Factor in
Morbidity and Mortality of Hemodialysis Patients, Kidney Int'l, 24 (supp.16): S199-203
(1983).
3. Devries, A. Rojas, C., Jacobs, C., Mortality Risk Factors in Patients Treated By
Chronic Hemodialysis. Nephron, 31: 103-110 (1982).
4. Schoenfeld, P.Y., Henry, R.R., Laird, N.M., & Roxe, D.M., Assessment of
Nutritional Status of the National Cooperative Dialysis Study Population. Kidney Int'l 23
(Supp.13): S80-S88 (1983).
5. Lowrie, E.G. & Lew, N.L., Death Risk, in Hemodialysis Patients: The Predictive
Value of Commonly Measured Variables and an Evaluation of Death Rate Differences
Between Facilities, American Journal of Kidney Disease, 15(5): 458-482 (1990).
6. Port, F.K., Morbidity and Mortality in Dialysis Patients, Kidney Int'l, 46: 1728-37
(1994).
7. Held, P.J., Port, F.K., Gaylin, D.S., & Wolfe, R.A., Levin, N.W.., Blagg, C.R.,
Garcia J., & Agodoa, L., Evaluations of Initial Predictors of Mortality Among 4837 New
ESRD Patients: The USRDS Case Mix Study (abstract), Journal of American Society of
Nephrology, 2(3): 328 (1991).
8. Burch, M.F., Schoenfeld, P.Y., Gotch, F.F., Sargent, J.A., Wolfson, M.,
Humphreys, M.H., Nitrogen Balance During Intermittent Dialysis Therapy of Uremia, Kidney
Int'l, 14: 491-500 (1978).
9. Wolfson,M., Jones, M.R., Kopple, J.D., Amino Acid Losses During Hemodialysis
with Infusion of Amino Acids and Glucose, Kidney Int'l, 21: 500-506 (1982).
10. Luzar, M.A., Coles, G.A., Fuller, b.F. Slingenegar, A., DahDah, G., Bruit, C.,
Wone, C., Krefati, Y., Kesslr, M., Peluso, F., Staphylococcus Aureus Nasal Carriage and
Infection in Patients on Continuous Ambulatory Peritoneal Dialysis, NEJM 322:505-509
(1990).
11. Olshan, A., Bruce, J., Schwartz, A.B., Intradialytic Parenteral Nutrition
Administration During Outpatient Hemodialysis, Dialysis Transplantation 16:495-496
(1987).
-7-
12. Bilbrey, G.L., Cohen, T.L., Identification and Treatment of Protein Calorie
Malnutrition in Chronic Hemodialysis Patients, Dialysis Transplantation 18:669-700 (1989).
13. Cano, N., Labastie-Coeyrehourg, J., Lacombe, P., et al, Perdialytic parenteral
Nutrition with Lipids and Amino Acids in Malnourished Hemodialysis Patients. American
Journal of Clinical Nutrition 52:726-730 (1990).
14. Foulks, C.J., The Effect of Intradialytic Parenteral Nutrition on Hospitalization
Rate and Mortality in Malnourished Hemodialysis Patients, Journal of Renal Nutrition, 4,
(1): 5-10 (1994).
15. Capelli, J.P., Kusher, H., Camiscioli, T.C., Chem, S.M., Effect of Intradialytic
Parenteral Nutrition on Mortality Rates in ESRD Care, American Journal of Kidney
Diseases 6:808-816 (1994).
16. Chertow, G.M., Ling, J., Lew, N.L., Lazarus, J.M., Lowrie, E.G., Association of
Intradialysis Parenteral Nutrition with Survival in Hemodialysis Patients, American Journal
of Kidney Disease 24:
912-920 (1994).
-8-
Arthur R. Olshan, MD, PhD; Julie Bruce, RD; Allan B. Schwartz, MD, St. Agnes Medical Center and Hahnemann
University, Philadelphia, Pennsylvania 19107
Intradialytic Parenteral Nutrition Administration
During Outpatient Hemodialysis
Ten ESRD patients who continued to lose weight over six months, despite aggressive
electrolytes, 250 ml 50% dextrose (diabetic
dietary counseling and oral nutritional supplements, were selected for intradialytic paren-
patients) or 70% dextrose (nondiabetic pa-
teral nutrition (IDPN). A one-liter solution of IDPN was infused into the venous drip
tients), and 250 ml 20% Intralipid. IDPN
chamber during a four-hour hemodialysis treatment three times per week. Two months
was administered by an infusion pump in-
of IDPN led to a positive weight gain and improved appetite in eight patients, and
to the drip chamber of the venous outflow
a significant increase in serum albumin among all 10 patients.
tubing from the dialyzer. The infusion was
performed over the four-hour hemodialysis
treatment three times per week for two
P
rotein-calorie malnutrition and weight
(range 46-85 years). Seven were females,
months. The average amount of IDPN ac-
loss associated with anorexia remain
three males. Causes of renal failure were
tually administered to each patient per
serious problems in end-stage renal disease
diabetic nephropathy in two patients, renal
treatment was 886 ml (range 700-1,000 ml).
patients. 1-4 Weight loss may relate to non-
artery stenosis and accelerated hyperten-
renal systemic disease, gastrointestinal tract
sion in two patients, hereditary nephritis in
RESULTS
pathology, and negative nitrogen balance
one patient, multiple myeloma with amy-
Nine of 10 patients were below ideal
from glucose and amino acid losses during
loidosis in one patient, chronic glomerulo-
body weight at the initiation of IDPN (Ta-
hemodialysis. We selected 10 ESRD pa-
nephritis in two patients, and nephrosclero-
ble 1). The one patient (R.S.) still at ideal
tients from the St. Agnes Medical Center
sis in two patients. Weights were obtained
weight had lost 25 lbs or 17% of her usual
outpatient dialysis unit who continued to
postdialysis when the patient was as ede-
body weight over the six months prior to
lose weight over a six-month period despite
ma-free as possible. Ideal body weight was
initiation of IDPN. After two months of
aggressive dietary counseling and oral nu-
assessed from standard tables as 100 lbs in
IDPN, eight patients gained an average of
tritional supplements. They then received
a 60"-tall female plus five pounds for each
5.1 lbs (range 2-9 lbs) and had improved
intradialytic parenteral nutrition (IDPN)
extra inch in height, and 105 lbs in a 60"-tall
appetites (Table II). One patient with mul-
for two months with monitoring of changes
male plus six pounds for each extra inch in
tiple myeloma and amyloidosis on polydrug
in weight, appetite, and serum albumin.
height (weight statistics prior to initiation
chemotherapy lost two pounds. One pa-
of IDPN are listed in Table 1). All patients
tient with multiple hospital admissions for
PROCEDURE
received hollow fiber hemodialysis treat-
upper gastrointestinal bleeding and ampu-
The 10 ESRD patients to receive IDPN
ments for four hours three times per week.
tation of a gangrenous leg lost six pounds.
were selected by the dialysis unit nutrition-
IDPN consisted of one-liter solution of 500
Part of this patient's weight loss reflects the
ist (J.B.). Their mean age was 65 years
ml 8.5% crystalline amino acids without
below-the-knee amputation (Table III). Two
Table I: Study population.
Table II: Weight-gain group (8 patients).
Percent of
Percent of
Weight gain
usual body
Ideal body
over 2 mo.
Change In
Weight lost
weight lost
weight at
Patient
of IDPN
appetite*
over 6 mo.
over 6 mo.
initiation of
lb.
Patient
prior to IDPN
prior to IDPN
IDPN
lb.
HA
6
t
JC
7
4
HA
6
7
79
JC
8
8
92
JG
9
f
JG
27
18
86
SF
2
t
MW
7
9
97
RS
2
t
SF
10
13
95
HG
5
t
RS
25
17
100
MR
4
1
AG
12
11
88
CH
6
1
HG
9
11
85
MR
19
17
80
Average
5.1
CH
25
19
84
Range
2-9
Average
14.8
13
88.6
Range
6-27
7-19
79-100
*Evaluated by renal dietitian (JB).
Presented in part at the joint poster session of the American Society of Nephrology/National Kidney Foundation in Washington. DC. December, 1986.
DIALYSIS & TRANSPLANTATION. Volume 16, Number 9. September 1987
49
CONCLUSION
Table III: Weight-loss group (2 patients).
IDPN is beneficial for those ESRD pa-
tients not responding to several months of
Weight loss
over 2 mo.
Change In
nutritional counseling and maximum oral
Patient
of IDPN
appetite
dietary supplements. We recommend a two
lb.
month trial of IDPN for the subset of he
modialysis patients with refractory anorexia
MW
2
+
Multiple myeloma and amyloidosis on
and progressive weight loss. Nutritional
polydrug chemotherapy
benefit to the patients is demonstrated as
AG
6
t
Multiple hospital admissions for upper
positive weight gain, improved appetite
gastrointestinal bleeding and amputation
and significant increase in serum albumin
of a gangrenous leg
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D, et al. Protein malnutrition in the treatment
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rin. Eight of 13 dialysis patients had serum
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and 29% of 21 nondiabetic dialysis patients
in apparently healthy hemodialvsis patients (Ab
sea and flushing related to Intralipid infu-
had midarm muscle circumferences under
stract). Kidney Int 19(1):161, 1981.
sion. Subsequent to this pilot study, we
the fifth percentile, indicative of signifi-
4. Miller DC. Levine SE, Delia JA, et al. Nu
tritional status of diabetic and nondiabetic pa
have adopted a policy of initiating IDPN
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Wolfson and Kopple infused 39.5 g ami-
Nutr 44:66-69, 1986.
Intralipid two weeks later.
no acids and 200 g dextrose during hemo-
5. Borah M. Scoenfeld P, Gotch F, et al. Ni
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Malnutrition is not uncommon in the
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6. Wolfson M. Jones M, Kopple JD. Amine
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evaluated the nutritional status of 37 he-
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1982.
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age of ideal and usual body weight, triceps
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skinfold thickness, muscle mass, serum al-
weight loss despite aggressive nutritional
bumin, transferrin, and total lymphocyte
counseling for IDPN. All patients received
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3. Kleinknecht D, Jungers P. et al. Uremi
evaluated the nutritional status of 13 mid-
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4. Wesson DE, Mitch WE, et al. Nutrition:
had not been hospitalized for one year. De-
significant increase in serum albumin
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spite this, comparison with 60 normal con-
among the 10 patients.
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JM Lazarus, pp. 618-642. Philadelphia: W.P
Saunders, 1983.
5. Blackburn CL, Etter C. et al. Criteria fo
Table IV: Change in serum albumin after IDPN.
choosing amino acid therapy in acute renal fai
ure. Am 1 Clin Nutr 31:1841-1853, 1978.
Serum albumin at Initiation
Serum albumin after
6. Feinstein EI, Blumenkrantz MJ, et a
Patient
of IDPN
2 mo. of IDPN
Clinical and metabolic responses to parenter
g/dl
g/dl
nutrition in acute renal failure. Medicine 60:124
137, 1981.
HA
3.2
4.0
7. Mirtallo JM. Schneider PJ, et al. A compa
JC
3.6
4.1
ison of essential and general amino acid infu
sions in the nutritional support of patients wit
JG
4.1
4.5
compromised renal function. JPEN 6:109-111
MW
4.4
4.1
1982.
SF
4.0
4.3
8. Kopple JD. Cianciaruse B. Nutrition
RS
3.9
4.5
management of acute renal failure. in Surgica
AG
3.3
3.6
Nutrition, ed. JE Fischer, PP. 567-589. Bostor
Little, Brown, 1983.
HG
4.0
4.6
9. Borah MF. Schoenfeld PY. et al. Nitroge
MR
2.9
3.6
balance during intermittent dialysis therapy (
CH
3.1
3.5
uremia. Kidney Int 14:496-500. 1978.
10. Wolfson M. Jones R. et al. Amino aci
Average
3.7
4.1°
losses during hemodialysis with infusion of am
= Standard deviation
+ 1.4
= 1.0
no acids and glucose. Kidney Int 21:501-50
1982.
<0.01.
C 11. Kopple ID. Nutritional therapy in kidne
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496
THE WHITE HOUSE
WASHINGTON
August 10, 1995
Ms. Nancy Chupp
Church Women United
Washington Office, Box 16
110 Maryland Avenue, NE
Washington, DC 20002
Dear Ms. Chupp:
Enclosed please find copies of the letters that were sent to
the women who submitted questions at your Forum on Women's Health
last year. The questions were forwarded to the Office of the
First Lady by Barbara Woolley.
Because the legislative environment surrounding health care
has changed so dramatically since the forum was held, we
responded to the questions by providing an update on the
President's health care reform efforts. Thank you for your
patience in awaiting a response.
Sincerely,
Jennfer Keen
Jennifer Klein
Senior Policy Analyst
CC: Barbara Woolley
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Gail Nicholas Magruder
Director
Health Ministries
M Division
5007 Sangamore Road
Bethesda, Maryland 20816
Dear Ms. Magruder:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
so that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Helen H. Mitchell
The BFM Group
Human Resource Development
38 Hawthorne Court, N.E.
Washington, D.C. 20017
Dear Ms. Mitchell:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health'.
I am writing to give you an update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
HilaryCodhom Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Kristina Peterson
114 High
Mannington, West Virginia 26582
Dear Ms. Peterson:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an' update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
HilaryCodhem Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Peggy Halsey
Apartment 306
34 Plaza Street
Brooklyn, New York 11238
Dear Ms. Halsey:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Hilary Porthem Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
The Reverend Betsy Z. Halsey
3261 Chestnut Avenue
Baltimore, Maryland 21211
Dear Reverend Halsey:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
so that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Nirmala Abraham
1758 Mendenhill
Hockessin, Delaware 19707
Dear Ms. Abraham:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an'update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Hillary Rodham Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Laia S. Katz
3550 Raymoor Road
Kensington, Maryland 20895
Dear Ms. Katz:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an' update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Carolyn Chupp
8645 West 250 N.
Shipshewana, Indiana 46565
Dear Ms. Chupp:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Hilary Podhom Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Vera S. Frasier
Post Office Box 447
Nokesville, Virginia 22123-0447
Dear Ms. Frasier:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an' 'update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Hillary Clinton
Hillary Rodham Clinton
THE WHITE HOUSE
WASHINGTON
August 2, 1995
Ms. Rebecca Erwin
9405 Chimney Way
Gaithersburg, Maryland 20879
Dear Ms. Erwin:
I very much enjoyed the opportunity to meet with you
last year to discuss health care reform at the Church Women
United's Forum on Women's Health.
I am writing to give you an' update on the President's
health care reform efforts. Recently, the President
announced a proposal to reach a balanced budget in ten
years. The President's proposal takes the first steps
toward health care reform by assuring that an individual
who loses his or her job will be able to pay for family
health insurance; by helping elderly or disabled Americans
get long-term care; and by reforming the insurance market
SO that Americans will not lose their coverage if they
change jobs, lose a job or get sick. The proposal will
also make coverage more available and affordable for small
businesses and the self-employed.
The President's plan improves Medicare by expanding
choice, offering new benefits, and extending the solvency
of the Medicare Trust Fund without imposing new cost
increases on Medicare beneficiaries. The plan will
preserve Medicaid as a safety net by protecting coverage
while reforming it to make it work more efficiently.
Measures such as these will make a difference in the
lives and health of American families. Once again, I thank
you for your interest in women's health, and I appreciate
your patience in awaiting a response. I encourage you to
remain informed and active in important issues like health
care reform.
Sincerely yours,
Hilary Podhem Clinton
Hillary Rodham Clinton
WASHINGTON
Church Women United
Washington Office, Box 16
President
110 Maryland Avenue NE, Washington, D.C. 20002
Ann B. Garvin
Telephone (202) 544-8747 Fax #: (202) 543-1297
General Director
Patricia Rumer
Supporting Organizations
February 27, 1995
of Church Women United
Airlives Methodist Epirospal Charch
(Women Missionary Society)
To:
Barbara Wooley
African Mothodist Exinempal Zion
From:
Charch
Nancy Chupp
(Women's Home and Overaue
Micromary Sectiony)
American Baytist Charches to the USA
(American Depair Former Minumer)
Christias Cherch (Disciples of Chartet)
I left a message on your phone machine this morning. My
(International Christian Women's
Fellowship)
apologies if it sounded garbled.
Christian Methodist Epincopal Charge
(Wemen's atumonery Council)
Cherch of God
It was good to see you last week at the meeting with Council of
(Women of the Church of God)
Caures of -
Presidents. Congratulations on your increased role as liaison on women's
(Program for Women)
Council of Hispenie American
issues. Let us know if we can do anything.
Ministries (Seementical)
(Women Department of COMAM)
Cumberiand Cherch
Prestrytention Woman)
1 ast April Church Women United sponsored a televised forum on
The Epincapal Charch
women's health with the First Lady. Many of our members were able to
(Epiropal Charch Women)
The Latheren Check in
ask questions. Due 10 lack of time, some were unable. During the hour
America
(Women of the Evergalizal Luthman
taping, the First Lady invited people in the audience who didn't get to ask
- in amount
General Convention of the New
questions to send them to the White House. I collected them and sent
Investion (Fundesbergian)
- Now Chank -
them last April, but they were never responded to, probably due to the
Cresk Orthodon Charch of North we
overwhelming demands on the White House on this issue last year.
- Actories
CLaudies Philopeacher Society)
International Comment of Community
Charches
Although the health care issue has changed dramatically and the
(Wament Christon Pelionship)
Address Charch Women
Administration's plan is no longer on the table, would it be possible to have
United
- Rellawship)
these questions responded to? As an organization, we constantly try to
Mercrian Charch in America
(Women's Boards Northarn and
empower our members politically and to combat the growing cynicism that
"my voice doesn't count anyway." It would help tremendously if the
National Baptist Convention of America
(Servior Women's Authory)
questions askers received some kind of response from the White House.
National Hopsist Commetion, USA. Inc
(Women's Convention)
Prosbyterian Cherch/USA
(Prubysonan Women)
As always, it's a pleasure working with you. Thanks for your
Programine National Deptist
consideration to this issue.
Commention, See
(Women's Department)
Reformed Charch is America
(Reformed Charch Women)
Beligious Seciety of Friends
(Unlted Society of Friends Woman
Increasional)
Reorgacized Charge of Jeens Christ of
Later Day Sales
(Women's Ministries Commission)
United Charch of Christ
(Coardinating Conter for Women in
Charch and Society)
The Uptted Methodies Charch
(Women's Division)
Church Women United is a national movement of Protestant, Roman Catholic, Orthodox and other Christian women.
0000000707
NCC WASHINGTON
PAGE
70
Church Women United
Washington Office, Bar 16
President
110 Maryland Avenue NE. Washington, D.C. 20002
Ann B. Garvin
Telephone: (202) 344-8747 Fax #: (202) 543-1297
General Director
MONTOR
Patricia Rumer
Supporting Organizations
of Church Women United
Africas Methodist Epirospal Church
(Wemen's Missionsly Society)
African Methodist Enincopal Zisa
April 26, 1994
Charch
(Women's Home and Oversur
Missionery Society)
Address Deptist probee is the USA
Mrs. Hillary Rodham Clinton
(American Septime Warman's Minismiss)
Carletise Cherra (Disclules of Christ)
Office of the First Lady
International Chamas Wamen's
The White House
Following)
Christian Methodist Enternal Church
Washington D.C. 20500
(Women's Minisory Caincil)
Charch of God
(Remar of the Charched God)
Charch of the Brotherds
Dear Mrs. Clinton
(Program)
Council of Elepanic American
Ministries
Thanks again for participating in our national televised forum on
(Wemen's Department of COHAM)
Cumberland Probyteries Charch
women's health on April 15. Your presentation and answers to our many
(Cumbarland Proshytenan Woman)
The Epiroopal Charch
questions were very clear and easily understood. Many women commented
(Epissopal Check Woman)
The Evangelical Letterns Charch is
afterward that you illustrated an amazing ability to make a very complex issue,
America
accessible and understandable.
(Women of the Evergatical Luther
Owek in America)
General Convention of the New
As you noted, there were many more questions than time allowed. In
(Aliance of New Claum Woman)
Grank Orthodox Cherch of North and
response to your invitation that questions be sent to the White House for a
South Amorican
(Laim Philopeacher Section)
written response, Church Women United's Washington Office has been
International Cremeti of Community
Charahes
collecting questions for the last week. I now turn them over to you with names
(Women Charges
and addresses.
Kerean American Charch Washes
Valted
(Ecuminal Fallowship)
Moraview Chard is America
Thanks again for your participation in our health care dialogue
(Women Boands-Nartham and
southern Provences)
as well as taking time to answer these follow up questions.
Nademal Repairs of America
(Senier Woman's Antiliary)
Nadesal Bapus: USA
Sincerely,
(Women's Communion)
Procbyterism Chereb/USA
(Prodysentan Warriers)
Programine National Regular
Convention, Isc.
Namy Chapp
(Wament Department)
Referred Charch la Atteries
(Reformed Charch Women)
Nancy Chupp
Religious of Friegds
Legislative Director
(United Society of Friends Women
Insurational)
Charch of Class be of
Latter Day Sales
(Women Ministries Commission)
United Charch of Carlot
(Coordinadag Conter for Women in
Church and Seciem)
The United Mothodist Cherch
(Women's Division)
Church Women United is a national involvement of Protestant, Roman Casholic. Orthodox and other Christian women.
WASHINGTON
QUESTIONS FROM WOMEN'S FORUM ON HEALTH CARE - APRIL 15, 1994
1.
Gail Nicholas Magruder, M.Div., Director, Health ministries, 5007 Sangamore Road,
Bethesda, MD 20816.
QUESTION:
Part of preventive care means paid access to acupuncture, Chiropractic "touch for
Health," nutrition advice by trained people (not M.D.'s) the receive little or no medical
school training re: nutrition. Are you going to guarantee these?
2.
Helen H. Mitchell, The BFM Group - Human Resource Development, (202) 387-0213.
QUESTION:
Was consideration given to dealing only with those who do not have health care?
3.
Kristina Peterson, 114 High, Mannington, WV 26582. (Member of Presbyterian
Health Network).
QUESTION:
Regarding highly rural, low population areas with citizens of high risk population. there
are no doctors. There is no incentive even with full payment of patient care since there
are not a lot of patients due to low population. Can there be other incentives like
government subsidy for a full salary to those who will go to underserved areas and also
the paying off of medical school bills?" Also critical to rural areas is presentative
education and health care - what can you do?
4.
Peggy Halsey, 34 Plaza St., Apt. 306, Brooklyn, NY 11238.
QUESTION:
How will the Administration's plan guarantee that adequate research is funded and
proper oversight given on specific issues of women's health?
5.
Rev. Betsy z. Halsey, 3261 Chestnut Ave., Baltimore, MD 21211.
QUESTION:
I am encouraged by the Administration's emphasis on preventative care. Would you
please explain how this applies to mental health care. Will there be caps on this
particular health care service?
6.
Nirmala Abraham, (Mar Thoma Church), home address: 1758 Mendenhill, Hockessin,
Delaware 19707.
QUESTION:
Malmutrition is premalent among elderly. As more and more people, especially women are
living longer, malnutrition has an impact on the health care dollars. Malmutrition results
in increased infection and disease. My question is: Will the President's health care
reform plan have coverage for nutrition counseling?
7.
Laia S. Katz, Vice President, Women of Reform Judaism. Home address: 3550
Raymoor Road, Kensington, MD 20895.
QUESTION:
You spoke to the need for a broad range of services for women pre-natal, etc. Will a
bottom line be the right to choose not to need pre-natal services as part of the right W u
guaranteed package of benefits, or can this right be lost to the give and take of legislation
given up by the Administration in return for others benefits?
8.
Carolyn Chupp, 8645 W. 250 N. Shipshewana, Indiana 46565.
QUESTION:
Thank you for an excellent presentation on April 15 and your commitment to universal
health care. My question about Health Care Reform: Will every citizen be required to
join a health care plan? For example, the Amish and other conservative groups do not
believe un insurance coverage because of being too closely tied with the government. As a
group, they cover each other's medical expenses.
QUESTION,
My husband owns a small bakery (of 22 employees in u rural area) and employs mostly
Amish employees. Would he be required to take out insurance for each of them even if
they do not want it? Since he does not currently pay for health coverage, I am not sure
he could continue to keep the business open How does your plan guarantee that small
businesses, such as my husband's, would not be forced to close because of the extra high
expense?
9.
Vera S. Frasier, P.O. Box 447, Nokesville VA 22123-0447.
QUESTION:
Will HMO be good only in the state where the policy card is issued or will is be patid
across the horder? Will it be valid in states and the U.S. Territories outside the
Continental USA?
10.
Rebecca Erwin, 9405 Chimney Way, Gaithersburg, MD 20879 (301) 926-1694.
QUESTION:
I ask from the perspective of a mother of a handicapped child: Will modical-related
services be provided that are not life and death health issues, but will improve quality of
life and productivity of humlicapped individuals? Services like intensive speech therapy
and physical therapy are not fully covered under the Federal Laws pertaining to the
education of handicapped children Will the pools of health care providers include a plan
for these services that is fair in cost or will those infirmations with extensive needs and up
paying more for much needed services than a "healthy' individual? The choice of health
provider pools could result in people who use medical services as a greater frequency being
forced to buy a more expensive plan, thus the neediest will pay more than the healthiest.
How ethical is this method? How does it address the needs of handicapped people?
THE WHITE HOUSE
WASHINGTON
July 20, 1995
Jack Kushner, M.D., M.G.A.
20 Ridgely Avenue
Annapolis, Maryland 21401
Dear Dr. Kushner:
Thank you for sending your health care plan. Carol Rasco,
Assistant to the President for Domestic Policy, received it from
Leon Panetta and asked me to respond.
Your plan includes many features that are important to the
President. As you know, the President supports your goal of
universal coverage. You will be pleased to know that some of the
insurance problems you identified were addressed by the President
in the health reform initiative that he announced as part of his
recent budget proposal. Specifically, the proposal would reform
the insurance market to ensure that Americans can keep their
coverage if they change jobs and will not lose or be denied
coverage if they have a pre-existing condition. It would add
important consumer protections by requiring insurers to provide
consumers with specific information on their plans as well as to
establish grievance and appeals procedures. In addition, the
initiative would subsidize insurance for working families for six
months after a job loss and improve the availability and
affordability of coverage for small businesses.
However, your plan includes several elements that the
Clinton Administration would not support. The Administration
does not promote ending tax deductibility of insurance. In fact,
as you may know, the Administration has recently proposed to
extend the tax deductibility of health insurance for individuals
who are self-employed. Nor would the Administration support the
abolition of Medicare. The Administration seeks to preserve and
strengthen Medicare while making it more efficient.
Additionally, while assessing the financial implications of
the proposal is impossible without more details, your proposed
premium of $4,500 per couple is low. Currently, the average cost
per Medicare couple is about $9,500 and per Medicaid couple is
$7,400. The cost for a federal employee and his or her family in
the Blue Cross/Blue Shield standard plan is $4,710. Given these
costs and the generous subsidies you described, it seems as
though your proposal would be difficult to fund.
Jack Kushner, M.D., M.G.A.
July 20, 1995
Page two
Thank you again for sharing your suggestions with us. We
will keep them in mind as the Administration continues to work
toward health care reform in the coming months.
Sincerely,
Jennfer Her
Jennifer Klein
Senior Policy Analyst
CC: The Honorable Carol Rasco
THE WHITE HOUSE
JUN 22 1995
WASHINGTON
June 5, 1995
Dr. Jack Kushner
20 Ridgely Avenue
Annapolis, Maryland 21401
Dear Dr. Kushner:
Thank you for your letter submitting a health care plan for
the United States. I appreciate your contacting me concerning
this important issue.
In order to give your health care plan the appropriate
attention, I have forwarded your letter and the plan to Carol
Rasco, Assistant to the President for Domestic Policy, and asked
that she or a member of her staff respond to you directly.
Please be assured that your health care plan will receive the
proper review.
Once again, thank you for writing.
Sincerely
Loon E. Panetta
Chief of Staff
CC: The Honorable Carol Rasco
LEP/tab
5-02-1995 19PM
FROM JACK KUSHNER M.D. 410 269 1457
P.2
NEUROSURGERY
JACK KUSHNER. M.D.. P.A.
DIPLOMATE AMERICAN BOARD OF NEUROSURGERY
FELLOW AMERICAN COLLEGE OF SURGEONS
FELLOW INTERNATIONAL COLLEGE OF SURGEONS
MASTER GENERAL ADMINISTRATION - FINANCE
May 2, 1995
Mr. Leon Panetta
The White House
1600 Pennsylvania Avenue
Washington, DC 20500
RE: Health Care Plan for the
United States
Dear Mr. Panetta:
I would like to submit to you a health care plan for the United States
which was written by Dr. Rose Rubin, Professor of Economics at the
University of Memphis and me. We feel that this represents a compromise
between the Republicans and Democrats on an issue that is so important to
everyone in our country. I have already sent this to numerous Republicans
in Congress and thus far I have not received an answer from anyone except
for Nancy Kassenbaum and Wayne Gilchrist who stated that they could not
support the plan.
Please review the plan and see whether or not there are any elements
in it which you find supportable. If you have any additional ideas as to
where I should send this plan for consideration, please let me know. Best
regards.
Sincerely,
Jach Jack Kushner, Kenten M.D., M.G.A.
JK/lls
Twenty Ridgely Avenue. Annapolis. Maryland 21401
Telephone (410) 268-3004
Fax (410) 269-1457
1-800-398-5219
6-30-1995 9:52AM
FROM JACK KUSHNER M.D. 410 269 1457
P.3
A Health Care Plan for the United States
Jack Kushner, M.D.
and
Rose Rubin, Ph.D.
Most Americans and politicians would agree that the United States has the best
health care in the world and also would agree that something has to be done to change the
way it is financed. None of the health care reforms thus far proposed has proved to be
politically viable. Now that we have a new Congress, perhaps some sort of compromise
arrangements can be realized. We propose a new and different health financing system that
would provide coverage for all Americans and would still allow them flexibility and choice.
Our proposed health care system combines Republican and Democratic tenets. It is
based on a continued private-public mix of ownership and control of health care resources
and delivery, which could continue to be for profit or not for profit; and it features diverse
sources of health care financing. This is a universal coverage plan, which would entitle
every American citizen and legal resident to a universal health care card. It would settle
divisive issues such as pre-existing illnesses, portability, employer mandates, and
preferential tax deductions. This plan would be utilitarian in that the government could
finance care for the poor, and yet it would be libertarian in that those households which
choose to do so could purchase additional health care.
This health plan starts with removal of the tax deductions for employer purchased
health insurance. Members of Congress are currently discussing proposals to modify the
Internal Revenue Code. This change would also disembarrass employers of paying for
health insurance, which interferes with American competitiveness in the international
economy. The national health insurance plan would give participants a choice of either an
indemnity insurance carrier or a managed care HMO. Furthermore, participants would
know that all services are supplied by participating providers at pre-negotiated rates. As
opposed to health insurance in the private sector, the national health insurance plan would
rebate a prorated amount of their premium if their benefits were not fully utilized. It would
settle the issue of insurance portability, because workers could purchase insurance
themselves and retain it when they change jobs. Households would have a choice of ways
5-02-1995 20PM
FROM JACK KUSHNER M.D. 410 269 1457
P.4
to finance their health care. They could pay out of pocket, purchase private indemnity
insurance or obtain managed care coverage. Rather than having predominantly
employment based group private insurance or only government financing we recommend
the following changes:
*Health insurance payments would not be tax deductible and would be based on
reported household income.
*Pre-existing diseases, community and experience ratings, and portability would no
longer be factors since there would be universal coverage.
*Payment for the health care credit card would be based on household income level
and size. Whereas a husband and wife without children would pay $4500 per year ($375
per month) for this health care, a family with children would pay more and a single person
would pay less.
*All citizens and legal residents would receive a health insurance credit card. For
example, a household with a husband and wife would use the card to receive health care
purchased with the annual $4500 ($375 per month) health insurance premium, as well as
the major medical insurance benefits with limits up to $100,000.
*A husband and wife with an income of $35,000 or more could purchase private
insurance, either indemnity or managed care, and indicate this choice on their tax return
with proof. Alternatively, they could participate in the government-sponsored health
insurance program and receive a prorated rebate if they did not fully utilize their benefits.
This rebate could take the form of cash or the credit could be applied toward their income
taxes the following year. The household would get the rebate rather than each person.
A husband and wife with an income less than $35,000 would pay only $2500 per
year ($208 per month) for their $4500 policy and a $100,000 major medical insurance
policy. This group could also choose whether it wantedits care provided by indemnity
insurance or the managed care system that participates with the government plan. Although
the husband and wife would still receive $4500 of health insurance benefits and the
$100,000 major medical insurance policy, their rebate would be prorated based on the
$2500 payment.
The third tier of the system would provide health coverage for households that have
income below the federal poverty level. These households would be insured under the
government sponsored managed care system and would not be eligible for any rebate.
5-02-1995 12:20PM
FROM JACK KUSHNER M.D. 410 269 1457
P.5
Inportantly, this plan would separate health care financing from welfare payments for low
income households providing motivation to enter the job market while retaining health care
financing.
Although any universal health care plan will incur increased costs, the government
could increase its revenues and finance this plan by:
1) Eliminating the tax deductibility of employer purchased health insurance.
2) Receiving increased taxes from the wage increases that many employees would
receive from their employers in lieu of health insurance.
3) Receiving revenues from premium payments for government sponsored health
insurance policies.
4) Abolishing Medicare and the acute part of Medicaid. (However, one area of
government revenue would be reduced, as there would no longer be a Medicare
supplemental tax of 1.25% on income).
5) Abolishing other federal and state health programs for specific conditions, such
as end-stage renal disease.
6) Transforming the Veteran's Administration Hospital system could be
transformed into geriatric acute care facilities and into long term health care centers for the
anticipated increased number of people receiving these services.
This health care plan would save the American public and businesses millions of
dollars. For example, individuals would no longer need medical insurance as part of their
automobile insurance policy. The medical care component of workman's compensation
insurance could be deleted, reducing another cost of employment to business. In addition,
medical malpractice awards would be reduced.
This broad health financing plan provides universal coverage and allows more
Americans to participate in their health decision making with positive, rather than perverse,
incentives for rational cost conscioiusness. Many households will opt out of the national
health insurance plan. Some will choose to stay in the government-sponsored plan, with
increased information regarding the cost of their health care decisions and with the ability to
select an indemnity or a managed care system. While the issue of health care is still in the
mind of America, we feel there is room for compromise with this plan.
THE WHITE HOUSE
WASHINGTON
July 6, 1995
Ms. Sandy Isenberg
President
Board of County Commissioners
County of Lucas
One Government Center
Suite 800
Toledo, Ohio 43604-2259
Dear Ms. Isenberg:
Erskine Bowles asked me to respond to your letter of June 8.
Thank you for your support of the First Lady's breast cancer
awareness campaign and for your interest in the Food and Drug
Administration's (FDA) efforts to ensure the timely commercial
availability of devices used in the detection of breast cancer.
The Clinton Administration, including the FDA, shares your
goal of facilitating early diagnosis of breast cancer. Under the
Mammography Quality Standards Act of 1992, the FDA is charged
with ensuring high quality mammographic examinations and has
certified over 10,000 U.S. mammography facilities as meeting
federally-developed standards.
We also agree that women should have access to every safe
medical device that will aid in the early detection of breast
cancer. That is why the FDA works to expedite product
development and agency review of innovative products intended for
the treatment or diagnosis of life-threatening or seriously
debilitating diseases. You will be pleased to learn that in
September 1994, the FDA's Obstetrics and Gynecology devices
Advisory Panel, a group of outside experts, recommended that
studies be performed to ascertain whether medical devices, such
as the Sensor Pad, add benefit to conventional breast self-
examination. The FDA has been working closely with the
manufacturer to determine the kind of scientific data necessary
to judge the safety and effectiveness of the Sensor Pad device.
Thank you again for writing.
Sincerely,
Jennifer Keen
Jennifer Klein
Senior Policy Analyst
CC: The Honorable Erskine Bowles
OF COUNTY COMMESSIONER
COUNTY OF LUCAS
BOARD OF COUNTY
COMMISSIONERS
SANDY ISENBERG
LUCA COUNTY OHIO
President
June 8, 1995
BILL COPELAND
MARK L. PIETRYKOWSKI
EDWARD J. CIECKA
Administrator
NANCY POSKAR
to
Clerk
Suno DPC
Mr. Erskine Bowles, Assistant to the President
and Deputy Chief of Staff
Executive Office of the President, 1st Floor, West Wing
1600 Pennsylvania Avenue, N.W.
Washington, D.C. 20500
Dear Mr. Bowles,
The new cancer awareness program headed by Hillary Clinton is commendable. However,
I feel this program will have no true significance or impact without the support of the Food and
Drug Administration (FDA).
As a female with a family history of breast cancer, I know first hand the emotional
devastation of this terrible disease. There continues to be an overwhelming need for products and
devices designed to aid women in the early detection of breast cancer. It is my hope that Dr.
Kessler will realize the importance of these life saving devices. The FDA needs to re-evaluate its
laboratory and clinical process and promote the marketing of these products, including the senor
pad.
The FDA needs to get back on track and function as part of the White House team.
Janey Sandy Sincerely, Isenberg, President Iseily
Board of County Commissioners
Lucas County, Ohio
ONE GOVERNMENT CENTER
SUITE 800
TOLEDO, OHIO 43604-2259
(419) 245-4500
An Equal Opportunity Employer
Fax (419) 245-4299
printed on recycled paper
2
THE WHITE HOUSE
WASHINGTON
July 6, 1995
John H. Olwin, M.D.
9631 Gross Point Road
Skokie, Illinois 60076
Dear Dr. Olwin:
I am writing in response to your letter to Leon Panetta
about chelation therapy.
The National Heart, Lung, and Blood Institute (NHLBI) has
followed the scientific literature on chelation for the treatment
of heart and vascular disease for more than 25 years. There are
proponents of chelation therapy who have made very strong claims
for its effectiveness. However, the only scientifically sound
research on chelation therapy for the treatment of
atherosclerosis has demonstrated no beneficial effects when
compared to dummy or placebo therapy.
I have enclosed a copy of the NHLBI's informational summary
on chelation therapy. Since the date of that report, another
scientifically sound study of patients with atherosclerosis
involving arteries of the lower extremities found no differences
in outcomes between patients who received active drug and those
who received placebo.
As you point out, it is possible that existing studies have
been inadequate and the National Institutes of Health (NIH) would
welcome grant applications for chelation therapy research. The
vast majority of research sponsored by the NIH is investigator-
proposed and since the NHLBI began following chelation therapy
only two of 40,000 proposals have focused on it.
I have taken the liberty of forwarding your letter to Dr.
Peter L. Frommer, Deputy Director of the NHLBI. If you have
further questions or are interested in submitting a research
grant application, please feel free to contact Dr. Frommer at
(301) 496-1078.
Sincerely,
Jennifer Kee
Jennifer Klein
Senior Policy Analyst
CC: Leon E. Panetta
HUMAN
SERVICES
DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
in
National Institutes of Health
National Heart, Lung, and
Blood Institute
Bethesda, Maryland 20892
CHELATION THERAPY - AN INFORMAL SUMMARY
The goal of chelation therapy for treating arteriosclerosis (or
atherosclerosis) is decreasing the narrowing of arteries by the
removal of calcium. Calcium is present in some arteriosclerotic
lesions. The drug used, disodium EDTA (disodium edetate, Endrate)
grasps or binds calcium, and the hope is that it will grasp calcium
from these areas of arterial obstruction.
Such "chelation therapy" is commonly accompanied by other therapies,
such as trace element "supplements," large doses of vitamins and
dietary modifications. Nevertheless, the central element of
"chelation therapy" is repeated intravenous infusions of disodium
EDTA.
There is no sound evidence that chelation therapy works -- that it
is effective or has clinical benefit.
There is also an important fallacy in this underlying idea. When
disodium EDTA is administered intravenously, it encounters calcium
everywhere in the blood and it binds calcium from the blood, not
from the tiny deposits of calcium that may exist in arteriosclerotic
lesions. The bound calcium is removed from the body through the
kidneys. The calcium in blood is replenished by calcium from the
bone, which is easily accessible to the blood stream, or by calcium
from the gut.
The advocates of "chelation therapy" have testimonials from people
who feel that their symptoms have been relieved. However, there is
no clinical trial or clinical study with scientific merit that has
shown the purported beneficial effects. Until August, 1991, the
best study was published in 1963. It concluded that "we believe
that chelation as used in this study did not benefit patients more
than other commonly used therapeutic methods. It is not a useful
clinical tool in the treatment of coronary artery disease at the
present time". By today's standards, that study has some
shortcomings but there is no subsequent study to contradict those
results. In August, 1991 and early 1992, reports were published of
a large, scientifically sound clinical trial that carefully
documents that chelation therapy does not work. Symptoms, clinical
findings, x-rays, and other measurements were compared in patients
who received the chelation therapy and compared to similar
measurements in patients who received a "dummy" therapy instead of
chelation. The results were identical; chelation therapy was shown
to be of no value.
2
CHELATION THERAPY - AN INFORMAL SUMMARY
What about people who have felt better following chelation therapy?
In the objective assessment of a variety of medical therapies,
including some for arteriosclerotic disease, people have often felt
much better in response to sham therapy or "placebos." Indeed, the
more dramatic the intervention, the more likely the effect. The
more someone has invested in feeling better -- and a course of
chelation therapy may be on the order of 30 to 50 intravenous
infusions over several months and costs thousands of dollars -- the
more likely a person is to be convinced that there has been a
benefit.
It might be noted that "chelation" is a chemical term meaning that a
compound grasps a metallic element to form a ringed structure. In
that sense, some forms of chelation are accepted and appropriate
forms of therapy. For example, deferoxamine is a validated therapy
in the management of iron overload following repeated blood
transfusion and EDTA, similar to that used in chelation therapy of
arteriosclerosis, is appropriate and accepted for the treatment of
lead poisoning.
This has nothing to do with the alleged benefits of chelation in the
management of arteriosclerosis. There is no reason to expect
benefit from chelation in the management of arteriosclerosis. More
importantly, there has been no scientific evidence of such benefit -
- and now there is scientific evidence of no benefit.
June 1992
JENNIFER
THE WHITE HOUSE
WASHINGTON
PLEASE ACKNOWLEDGE
receipt directly.
May 24, 1995
Thanks,
Dr. John H. Olwin
9631 Gross Point Road
J.
Skokie, Illinois 60076
Dear Dr. Olwin:
Thank you for writing and sharing your suggestions regarding
a way to "bypass" health care costs accrued due to heart disease.
This Administration remains determined to fulfill the fundamental
principle of reform - - - guaranteed private health care coverage
for all Americans.
To give your ideas the proper attention, I have taken the
liberty of forwarding your letter to the appropriate health
policy staff at the Office of Domestic Policy. I can assure you
that your thoughts will receive careful consideration.
Thank you again for taking the time to write. I will keep
your views in mind.
Sincerely
Leon A Panetta
Chief of Staff
CC: Office of Domestic Policy
LEP/tab
John H. Olwin, M.D.
9631 Gross Point Road
RHR
Skokie, Illinois 60076
1-708-676-4030
MAR 1995
March 7, 1995
Mr. Leon Panetta
Chief of Staff
The White House
Washington D.C.
20500
Dear Mr. Panetta:
I very much enjoyed your interview Sunday on the David
Brinckley program and thought you handled the questions from Sam
Donaldson particularly well.
You have probably one of the most difficult positions in the
Administration and are probably better qualified for the job than
anyone who has tried it in this century. Quite a statement, but many
of my friends would agree.
Certainly, one of your most difficult problems at present is
that of Health Care. There is no easy solution to it, but having been a
part of it for sixty years I have a few suggestions about one of the
most pressing and costly problems in the field today, that of
coronary artery "bypass'. As you well know, most of these operations
are done on patients over 60 years of age and each costs $65,000 or
more. Some individuals have gone through the procedure two, three
and more times, at the above or greater cost.
There is a procedure that will almost surely prevent or
materially reduce the development of atherosclerotic obstruction of
the coronary arteries in most if not all individuals. It has been
neglected and or scorned by most of the medical profession, largely
because it has not been given an acceptable trial. The accompanying
material may answer questions as to its possible efficacy and cost.
I would suggest that two committees composed of competent
physicians be chosen. One committee would organize a controlled
clinical study of patients who are candidates for coronary by-pass.
Half of those candidates would proceed with the by-pass. The other
half will be given infusions of EDTA (ethylene diamine tetra acetic
acid). The second committee would judge the results of the two
procedures. Within one year following the completion of the two
procedures the comparative benefits of them should be apparent.
I have no doubt as to the outcome of the trial. And I believe
that the resulting changes in our methods of treatment of patients
with any type of atherosclerosis will result in at least an eighty-
five (85) per cent reduction in the present cost of such treatment.
Thank you for giving your time and attention to this letter. So
that your advisors in the fields of Health Care may have some basis
for judging my competence to write on such matters I am taking the
liberty of enclosing my Resumé.
Most respectfully,
John H. Ohion
John H. Olwin M.D.
RÉSUME
John H. Olwin
Fields of competence:
Trace metals; blood coagulation;
general and vascular surgery,
thrombo-embolism;
Professional Experiences:
atherosclerosis
Private practice of sclerotherapy for varicosities and venous blemishes
1978 to present.
Private practice of General and Vascular surgery 1939 to 1984.
Founder and Director of Clinical Coagulation Laboratory and of
Coagulation Research Laboratory, Presbyterian, and then Presbyterian-
St. Luke's Hospital, Chicago, Illinois, 1946 and 1947 respectively to
1969. Attending Surgeon, Presbyterian-St. Luke's Hospital, 1942 to
1972. Emeritus, General Surgery, Rush-Presbyterian-St. Luke's Medical
Center, Chicago, Illinois 1972 to present. Clinical Professor of Surgery,
Rush Medical College, 1942 to present. Consultant in General and
Vascular Surgery, Veterans Administration Hospital, Hines Illinois,
1946 to 1962. Special interest in the role of essential and toxic metals
and organics in cellular metabolism.
Education: B.A. University of Illinois, 1929. M.D. University of Chicago
(Rush Medical College) 1934. Internship, Presbyterian Hospital, Chicago,
Illinois 1935 to 1936. Residency (General Surgery) 1937 to 1939.
Research Fellow, Rush Medical College 1939-1940. Associate, General
Surgery, Cook County Hospital, 1939 and 1940.
Professional Activities American Medical Association, Chicago
Surgical Society, American College of Surgeons, Society for Vascular
Surgery (Recorder 1960 to 1966), Central Surgical Society, Western
Surgical Association, Chicago Medical Society, Illinois State Medical
Society, Institute of Medicine of Chicago (Secretary, 1970 to 1972;
President, 1973 to 1975), Committee on Thrombosis and Hemorrhage,
National Research Council, 1959 to 1964.
Military Service: Extended Active Duty M.C.AUS 1940 to 1946, .Lt.Col.
Chief of Surgery, 29th Evacuation Hospital, Bronze Star, three Battle
Stars.
Publications: Author or co-author of 151 papers in the areas of General
and Vascular Surgery, Blood Coagulation, Trace Metals and
Chronobiology.
CHELATION THERAPY
What is chelation therapy? It is the infusion of substances that
remove metals from the body. The word is derived from the Greek
word chela, the pincer claw of the crustean. Early investigaters saw
a similarity between the way these chemical agents bind metals and
the way the crustacean firmly fixes its prey. The metals are so
firmly bound that it is difficult for other chemicals to break that
bond. Chelating agents have been used in industry for many years to
separate metals from ores or from other metals.
The exact nature of the chemical action on the body, other than
the binding of metals, is not well understood. There are several
theories. The one I hold to is that we are removing toxic metals
which have replaced. in the various enzyme systems, the essential
metal(s) necessary to the normal functioning of that particular
enzyme system.. There are, at the present time, 15 trace metals
that are known to be essential to normal enzyme activity. Among
these are cobalt, chromium, iron, molybdenum, manganese, nickel,
selenium, tin and vanadium. Every cell contains more than 3000
enzymes and of these more than fifty per cent are so-called
metallo-enzymes. In these enzymes the metals are structural
components of the enzyme system. The remaining enzymes are
probably influenced by metals acting as co-enzymes or as catalysts.
Thus, almost no process goes on in the body without the aid of
metals. If these essential metals are replaced by toxic ones such as
lead, cadmium, mercury, aluminum or even an overwhelming amount
of some of the other metals, even the essential ones, these enzymes
are paralyzed. If we can remove these metals that are acting as
poisons, perhaps we can restore the enzyme systems to their normal
or near-normal activity and thus reverse the disease processes. In
removing the toxic metals, we also remove a number of the essential
ones. These, however, can be replaced by the food that we eat and by
the addition to our dietary routine of so-called nutrient
supplements, i.e. vitamins and minerals.
It would be a happy circumstance if we could feed this chelating
agent by mouth. However, when given orally most of it passes
through the intestinal tract without being absorbed and, in passing,
binds a number of the essential elements that we need. Hence, it
becomes necessary to give it either intramuscularly or
intravenously. Since the intramuscular route is painful and is less
well controlled, we give it intravenously. This is an inconvenience
and an expense but it is also painless and, being more easily
controlled, is much safer than the intramuscular route. The
inconvenience is that the patient must sit with a needle in his/her
vein for a period of three hours for an infusion. Since the material
2
that we use is an acid, even though a weak one --ethylene-diamine-
tetra-acetic acid (EDTA)- it must be given slowly SO as not to be
painful and so as to allow the body to absorb it more completely
rather than excreting it too rapidly. Unlike most drugs, it is not
broken down in the body into its component parts, but is excreted
just as it is given except that it has firmly bound a number of
metals. It is excreted in the urine and can be recovered (almost 100
per cent of it) in a relatively short period of time (hours). When
properly given it is entirely safe. Its only toxic effect is on the
kidneys and since we give it slowly and monitor each patient's
kidney function with each infusion, the hazard is reduced to zero. In
fact, we have some patients with badly damaged kidneys who, when
given the material cautiously, have been able to accept it and have
experienced an improvement in their kidney function.
it has been observed by competent investigators that arteries in
human beings obstructed by calcium and lipid (fat) deposits will,
over a period of months to years, become patent and will for the
most part remain so as long as the EDTA infusions are continued. The
artery walls will again be narrowed and the obstruction will recure
by similar calcium and lipid deposits if the infusions are
discontinued. These findings have been repeated in rabbits fed an
atherogenic diet. As stated earlier, one of the principle effects of
the infusion of EDTA is the removal of toxic metals such as lead,
cadmium, aluminum and mercury from the body, thus restoring
normal enzyme function. There is no doubt that all persons and
animals living in the cities of western civilization have elevated
levels of such metals. Some years ago we did a study of 100 patients
in Chicago and suburbs and found an elevated level of lead (the
"normal" then being 0 to 80 micrograms per 24 hour specimen of
urine} in 87 per cent of them. Sheep grazing near a freeway have
been found to have a heavy body-burden of lead. EDTA has been used
by the medical profession for years as the best treatment available
for lead poisoning. Another study from our laboratory showed that
cholesterol and all other blood lipids were significantly lowered
following the beginning of chelation therapy and remained lowered
as long as the therapy was continued. The lipid levels returned to
their former state about three weeks after the infusions were
discontinued. Other benefits following the initiation of chelation
therapy that I have observed have included the unblocking of
atherogenic obstruction in main leg arteries; dissolution, overnight,
of freshly lodged emboli; increase in collateral circulation, color
and warmth to a limb, and termination of gangrene; observed status-
quo of an abdominal aortic aneurysm in a patient on regular
chelation therapy over a period of thirty years; improvement in or
elimination of claudication; improvement in sexual desire and
performance in men and, in a very limited number of adults,
improvement in, or elimination of, the symptoms of Alzheimer's
3
Disease.
Unfortunately, the EDTA infusions must be continued in order
to maintain their various benefits. Nobody knows how often
treatment must be given. Over the years I have found that, after the
initial series of 20, one infusion every two weeks has been adequate.
A few patients have seemed to do well on monthly infusions. All of
those who have stopped the treatment completely have, within two
to three years, developed arterial closures and a return of their
previous conditions.
It is interesting to speculate on the possible influence of
universal chelation therapy on the health of the nation and on the
national health bill. At the current cost, the latter would be in the
neighborhood of $2500 to $3000 per person, per year, much less with
universal utilization. A coronary artery by-pass operation currently
costs $60,000. Other possible benefits of the elimination of toxic
metals in the body and the improvement of enzyme function are
mind-boggling. Fortunately infusions are easily and simply
administered and can be set up in every hamlet in the country.
As with Edward Jenner's claim in his discovery of smallpox
vaccination in the late 1770's and that of Louis Pasteur a century
later, when he told the doctors and mid-wives they were carrying
child-bed fever from patient to patient because they did not wash
their hands between cases,
original scorn and disbelief, by the
medical profession, will eventually turn to the acceptance of EDTA-
chelation therapy as a valuable and useful tool in the treatment of a
number of clinical abnormalities.
John H. Olwin M.D.
Clinical Professor of Surgery
Rush Medical College
For those who may wish to look further into the scientific bases
for, and the benefits of chelation therapy it is recommended that
he/she order a copy of a collection of papers by various scientists in
the field. It is 'A Textbook on Chelation Therapy" edited by Elmer M.
Cranton with a foreword by Linus Pauling. It can be obtained from
the American College of Advancement in Medicine, Edward A.
Shaw,M.B.A., Ph.D. Executive Director, 23121 Verdugo Drive. Suite
204, Laguna Hills, Ca. 92653 714 583 7666. The cost is
approximately $25.
THE WHITE HOUSE
WASHINGTON
June 19, 1995
Sabrina Mohammed
32 Asbury Place
Mt. Tabor, NJ 07878
Dear Ms. Mohammed:
Thank you for writing to share your ideas about teenage
pregnancy. Both the President and the First Lady care deeply
about children and are working to ensure that they are born into
caring and supportive family environments.
After approximately 30 years of decline, the rate of teen
pregnancy has begun to rise. In fact, in 1990 more than one
million women between the ages of 15 and 19 became pregnant --
almost 12% of all teenage girls. Sadly, many teenagers who have
children are unable to support them financially and therefore
must rely on public assistance. As you noted, having children at
a young age also makes it difficult for the parents to stay in
school or work, especially if they do not have access to
affordable child care.
The President and First Lady have launched a National
Campaign Against Teen Pregnancy to prevent unwanted pregnancies.
The campaign relies on leaders from all sectors of society --
business, media, entertainment, education, sports, churches, and
foundations -- to raise public awareness about the crisis of teen
pregnancy and to educate young people about positive life
alternatives so that they will abstain from sexual activity or
engage in careful family planning by using contraceptives.
I commend you for taking your school work seriously and
investigating issues that you care about. I wish you continued
success in your endeavors.
Sincerely,
Jennifer Ker
Jennifer Klein
Senior Policy Analyst
Sabrina Mohammed
32 Asbury Pl.
Mt. Tabor, N.J. 07878.
May 1, 1995.
The White House Office
1600 Pennsylvania Avenue.
N. W. Washington, D.C. 20500.
Dear Jennifer Klein:
My name is Sabrina Mohammed and I am seven-teen years of age. I am a
junior at Parsippany Hills High School, who is working on a project for my U.S. II
History class. This project deals with trying to make a change that I strongly believe in.
I believe that teenagers under the age of eight-teen years old who gets pregnant and is
not able to show the government that they are mature and will be able to support the
child, it should be taken away. The reason I feel this way is because there are so many
teenagers getting pregnant at young ages and getting on welfare. These teenagers then
stay on welfare for most of there lives and don't even try to better themselves, most likely
they will keep getting pregnant and get more money for the kids. Some just stay on
welfare because they like getting the checks and don't even try to get jobs. More and
more each day I personally see my young friends getting pregnant and having the kids
and sometimes never graduating high school.
The government should then decide whether to put the baby up for adoption or return
the baby to its parents after they are able to take care of the baby. They are so many bad
things happening to babies and so many people going on welfare. Their not doing
anything with their lives and are living off of welfare.
In doing much research on this topic, I have learned that about 75% of the people I have
talked to about this agrees with me. In a survey that I took about 50% agrees with me
on this topic, about 30% is undecided and 20% disagrees. I also put a petition together
that many people signed. I learned a lot about how people felt about this subject and I
have come to a conclusion that something has to be done about this problem of growing
teenage pregnancy. Hopefully you may be able to do something about this or just give
me your opinion even if you don't agree. Thank you.
Sincerely yours,
Sabrina Mohammed.
TEEN PREGNANCY (filename: teenpreg.tp)
JANET ABRAMS, 456-2857
3/13/95
TEEN PREGNANCY
"We've got to ask our community leaders and all kinds of organizations to help us stop
our most serious social problem: the epidemic of teen pregnancies and births where
there is no marriage. Tonight, I call on parents and leaders all across this country to
join together in a national campaign against teen pregnancy -- to make a
difference."
President Clinton, 1995 State of the Union
BACKGROUND: TEEN PREGNANCY IS OUR MOST SERIOUS SOCIAL PROBLEM
Twelve Percent of all Teenage Girls Got Pregnant in 1990 -- more than 1 million
women between the ages of 15 and 19 -- 12% of all teenage girls.
The rates are rising From the 1950s through the early 1980s, the rate of births to
teens declined steadily, however, between 1986 and 1991, the teen birth rate rose 24%.
The U.S. rate of births to teens is now twice as high as in the United Kingdom and six
times as high as in France, Italy, and Denmark.
And teen births are mostly outside marriage In 1960, only 15% of teenage mothers
were unmarried. By 1992, that percentage had increased to 71%.
In all Communities Out-of-wedlock childbearing has increased greatly among both
black and white teens. The rate of births outside marriage among black teenagers rose
from 64% in 1970 to 93% in 1992. For white teens, the percentage of births out of
wedlock more than tripled over the same period, from 18% to 61%.
THE IMPACTS
Children in Poverty 80% of children of unwed teen mothers who have not completed
high schoool live in poverty. In contrast, of children born to married parents at least
20 years old with a high school degree, only 8% live in poverty.
Mothers on Welfare More than three-fourths of all unmarried teen mothers will be on
AFDC at some point during the 5 years following the birth of their child.
Other Social Ills Children of teenage parents are more likely to die in their first years,
have lower cognitive achievement, repeat a grade in school, be victims of abuse and
neglect, and become teen parents than children of older parents.
Society Pays In 1991, taxpayers spent about $34 billion to assist families begun by
teenagers. 42% of families receiving AFDC were started by teen mothers, age 15-19.
A NATIONAL CAMPAIGN AGAINST TEEN PREGNANCY
We've got to ask our community leaders and all kinds of organizations to help us stop our
most serious social problem: the epidemic of teen pregnancies and births where there is no
marriage. Tonight, I call on parents and leaders all across this country to join together in a
National Campaign against Teen Pregnancy -- to make a difference.
President Bill Clinton
1995 State of the Union Address
President Clinton has urged the American people to join together in an effort to stem the
epidemic of children having children. He has outlined a plan of action which requires
leadership by both the private and public sectors. "Government," the President has said, "can
only do so much" to break the debilitating cycle of teen pregnancy and poverty.
Private Sector Initiative
As envisioned by the Administration, leaders from all sectors of society -- business, media,
entertainment, education, sports, churches, and foundations -- would create an independent,
not-for-profit organization to focus the resources and talents of the private sector on the
complex problem of teen pregnancy. The organization would wage a nationwide campaign to
promote individual responsibility, as well as hope and opportunity, for America's youth.
Specific functions of the organization might include:
producing a national media campaign to raise public awareness about the crisis of teen
pregnancy and promote responsible behavior
supporting community-based initiatives which stress abstinence and pregnancy
prevention and educate young people on positive life alternatives
setting and monitoring national goals for reducing teen pregnancy and expanding
economic opportunities for youth
offering a forum for discussion of key issues by interested groups across the country
providing training and technical assistance to local organizations
sponsoring research and evaluation of prevention programs
operating a clearinghouse for information on teen pregnancy and effective prevention
strategies
Reasons for Optimism:
Private-sector campaigns to influence social behavior have achieved considerable success.
The grassroots coalition Mothers Against Drunk Driving (MADD) has effectively
raised public awareness about the hazards drinking and driving and contributed to
significant change in Americans' behavior. Since MADD's inception in 1980, the
number of alcohol-related fatalities on U.S. highways has decreased by 39%.
In 1986, the privately funded National Partnership for a Drug Free America set out to
change Americans' attitudes about drugs through targeted media activity. Between
1987 and 1993, the Partnership focused $1.7 billion in advertising time on the issue.
Drug usage declined across all segments of society over that period, and anti-drug
sentiment grew significantly.
Numerous community-based initiatives have proven effective in reducing the incidence of teen
pregnancy.
In Atlanta, a program sponsored by Grady Memorial Hospital for eighth-graders
provides abstinence training and contraceptive education. Children who entered the
program sexually inexperienced were found to be five times less likely to become
sexually active by the end of the school year than their non-program peers.
In New York, the Adolescent Pregnancy Prevention Program (APPP) of the Children's
Aid Society takes a holistic approach, offering girls and boys a wide range of services,
including Family Life and Sex Education, Medical and Health, Job Club and Career
Awareness, and Homework Help. Every participant who graduates from high school
or earns a General Equivalency Diploma is guaranteed admission to Hunter College.
Of the 250 teenagers who have participated in the Harlem APPP during the past 9
years, only eight girls have become pregnant out of wedlock, and two boys are known
to have fathered children.
In Partnership with Government
In 1992, Bill Clinton made the groundbreaking commitment to "end welfare as we know it."
The President's reform plan included several measures to motivate young people to make
responsible life choices:
Teen mothers on welfare would be required to live at home with their parents, stay in
school, identify the father, and move into employment within a limited period of time.
Tough new child support laws would be strictly enforced, so that prospective teen
fathers would know they had to provide child support for the next 18 years.
States would have the flexibility to try innovative ways to encourage responsible
behavior, such as rewarding teen recipients who make progress in school and
sanctioning those who drop out.
School-based teen pregnancy prvention programs in high-risk areas
A national teen pregnancy clearinghouse to disseminate information on.model
programs.
A NATIONAL CAMPAIGN AGAINST TEEN PREGNANCY
"We clearly need a national campaign against teen pregnancy that sends a clear
message: It is wrong to have a child outside marriage. Nobody should get pregnant
or father a child who isn't prepared to raise the child, love the child, and take
responsibility for the child's future."
President Clinton, March 7, 1995
President Clinton has urged the American people to join together to stem the epidemic of
children having children. He has outlined a plan of action which requires leadership from
both the private sector and government.
Private Sector Leadership
Recognizing that "government can only do so much" in
addressing the complex issue of teen pregnancy, the President is inviting leaders of all
fields -- business, sports, entertainment, education, churches, foundations -- to
contribute their energy and resources to addressing the problem. A private sector
campaign waged from boardrooms, t.v. stations, pulpits, and community centers across
the country would promote individual responsibility, as well as hope and opportunity,
for America's youth.
In Partnership with Government In 1992, Bill Clinton made the groundbreaking
commitment to "end welfare as we know it. The President's reform plan included
several measures to motivate young people to make responsible life choices:
Teen mothers on welfare would be required to live at home with their parents,
stay in school, identify the father, and move into employment within a limited
period of time.
Tough new child support laws would be strictly enforced, so that prospective
teen fathers would know they had to provide child support for the next 18
years.
States would have the flexibility to try innovative ways to encourage
responsible behavior, such as rewarding teen recipients who make progress in
school and sanctioning those who drop out.
School-based teen pregnancy prvention programs in high-risk areas
A national teen pregnancy clearinghouse to disseminate information on model
programs.
UPDATE
The House is marking up welfare reform legislation that takes a more punitive approach to
teen pregnancy, cutting off all benefits to mother and child until the mother turns 18. The
administration is opposed to this approach. Floor action will occur in late March, and the
Senate will take up welfare reform in April or May.
The National Campaign is in the development stages, as people outside the administration talk
to leaders in a wide range of fields about taking up the President's challenge.