1.  Women Pay Higher Premiums Than Men of the Same Age for Identical Individual Health Insurance Policies, Data Show

     Women generally pay "much more" than men for identical individual health insurance policies, according to data from insurance companies and online brokers, the New York Times reports. The Times analyzed premiums charged by major insurance companies like Humana, UnitedHealth Group, Aetna, and WellPoint subsidiary Anthem, health plan quote provider eHealth Insurance and state high-risk pools. The Times cites several examples of the disparity:

• Humana's "Portrait" plan -- which the company says offers "ideal coverage for people who want benefits like those provided by big employers" -- has a $2,500 deductible, and a woman pays 31% more than a man in Denver or Chicago and 32% more in Tallahassee, Fla.
  
  
• A 30-year-old woman in Columbus, Ohio, pays 49% more -- $92.87 monthly compared with $62.30 for a man -- for Anthem's Blue Access Economy plan.
  
  
• Most state high-risk insurance pools use sex as a factor in determining rates. Women ages 25 to 29 in Dallas or Houston pay 39% more than men of the same age for the Texas Health Insurance Risk Pool, and a 35-year-old woman in Nebraska pays 32% more than a man of the same age for coverage under the state insurance pool.
  
  
• A 30-year old woman in Iowa pays 48% more, $151 monthly compared with $102 monthly, than a man the same age for Wellmark's Select Enhanced plans.

Reasons
Insurance companies note that women between ages 19 and 55 often have higher health care expenses, especially during their childbearing years, the Times reports. In addition, women are more likely to visit their physicians more often than men to receive regular medical checkups, take prescription medications and address chronic ailments, according to the insurers. Some women still pay more for coverage under policies that do not pay for maternity care, while other coverage plans may charge women additional costs for maternity as an optional benefit, according to the Times. Elizabeth Leif, a health insurance actuary in Denver, said that many state insurance laws require insurers to cover the cost of caring for complications related to pregnancies, which insurers say can drive up costs. Rep. Xavier Becerra (D-Calif.) said that "if men could have kids" the disparities between coverage cost would not exist. Cecil Bykerk, president of the Society of Actuaries, said that if the disparity between women's and men's premiums were eliminated, women would pay less but "rates for men would go up."

Thomas Noland, a senior vice president of Humana, said, "Premiums for our individual health insurance plans reflect claims experience -- the use of medical services -- which varies by gender and age," adding, "Females use more medical services than males, and this difference is most pronounced in young adults." He said, "Bearing children increases other health risks later in life, such as urinary incontinence, which may require treatment with medication or surgery."

Critics
Marcia Greenberger -- co-president of the National Women's Law Center, which examined hundreds of individual policies -- said, "The wide variation in premiums could not possibly be justified by actuarial principles," adding, "We should not tolerate women having to pay more for health insurance, just as we do not tolerate the practice of using race as a factor in setting rates."

Some states, such as Maine, Montana and New York, have laws prohibiting gender-based premium rates for individual health insurance policies. In addition, civil rights laws ban employer-sponsored health plans from setting different premium rates for the same benefits based on gender, according to the Equal Employment Opportunity Commission.

A Look Ahead
According to the Times, the analysis comes as the sagging economy is forcing more people who have lost jobs that offered health benefits to purchase individual health plans. Meanwhile, Democratic and Republican lawmakers have proposed plans that would expand the use of the individual coverage market, such as tax credit programs for consumers or providing other assistance for people to purchase their own coverage. Greenberger said without significant changes to the individual coverage market, tax credits would be worth less to women because they would pay higher premiums (Pear, New York Times, 10/30).

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2.  Most Patients Satisfied With Hospital Care but Many Rate Communication, Pain Control Low, Study Shows

     A majority of patients are satisfied with the care they receive during a hospital stay but many are unsatisfied with communication and pain control, according to a study published on Thursday in the New England Journal of Medicine, USA Today reports. Authors examined data collected by the federal government in an ongoing patient survey at all hospitals that receive Medicare payments. In the study's first year, which ended Sept. 30, about 40% of eligible hospitals did not report their data.

Patients in the study, which was sponsored by the Commonwealth Fund, rated six areas on a scale of zero to 10, including communication by physicians, nurses, and about medications and the quality of nursing services, discharge information and pain management. Overall, 63% of respondents rated the quality of their care a nine or 10 and 26% rated it a seven or eight. The study found that about one-third of patients gave low scores for pain control and one-fifth gave low scores for discharge instructions. Researchers found that hospitals that ranked well on standard measures of quality had higher patient ratings. The study also linked a high nurses-to-patient ratio with higher patient satisfaction. In addition, the study found that teaching hospitals were rated higher than non-teaching hospitals, and not-for-profit hospitals were rated higher than for-profit facilities.

Lead author Ashish Jha, an assistant professor of health policy at the Harvard School of Public Health, said, "These data really represent a sea change," adding, "We've been talking about [health care] quality for 20 years, but patients' experiences have not been part of the discussion." Anne-Marie Audet, vice president for quality improvement and efficiency at CWF, said the negative responses to pain control and communication show that in those areas "no one is doing ... great" (Rubin, USA Today, 10/29).

The study is available online.

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3.  Employers Must Offer More Incentives for Worker Wellness Programs

     Employers that offer wellness programs to employees need to provide workers with more incentives to participate, according to benefits experts, the AP/Kansas City Star reports. According to experts, despite the current economic downturn, more employers next year likely will offer wellness programs in an effort to reduce their health care costs.

Annual surveys of Fortune 500 companies conducted by Towers Perrin have found interest in wellness programs among employers has doubled over the past five years. In addition, Aon Consulting predicts that the percentage of employers that offer health risk assessment programs will increase from 48% this year to 66% next year. Experts said that employers need to provide strong incentives, such as cash or discounts on health insurance premiums to maintain and increase participation in wellness programs.

Employers that in 2002 or 2003 offered $100 in cash to employees who participated in health risk assessment programs could expect participation from about 75% of workers, but by 2006 that rate decreased to about 50%, StayWell Health Management research director Jessica Grossmeier said (Murphy, AP/Kansas City Star, 10/28).

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ELECTION 2008

4.  Democratic Presidential Nominee Obama Addresses Health Care, Other Issues in 30-Minute Advertisement

     Democratic presidential nominee Sen. Barack Obama (Ill.) on Wednesday at 8 p.m. ET aired a 30-minute advertisement on seven television networks during which he discussed health care and other issues, Bloomberg reports (Jensen/Goldman, Bloomberg, 10/29). The ad cost more than $3 million (Slevin, Washington Post, 10/30).

During part of the ad, Obama stood before a desk and discussed his proposals for health care and other issues (Rutenberg, "The Caucus," New York Times, 10/29). Obama said that "every American has a right to affordable health coverage" (Woodward, AP/Boston Globe, 10/29). The ad also featured U.S. residents who discussed their personal concerns about health care and other issues (Kuhnhenn, AP/Bergen Record, 10/29). Obama also discussed worries his mother had about health coverage during her treatment for ovarian cancer ("The Caucus," New York Times, 10/29).

In advance of the ad, Republican presidential nominee Sen. John McCain (Ariz.) during a campaign stop in Florida said that Obama has "got a few things he wants to sell you," such as "offering government-run health care" (AP/Bergen Record, 10/29).

Additional Developments
Summaries of several other recent developments related to health care issues in the presidential election appear below.

• Center for American Progress: The center plans to release a 50-chapter book that lays out "how to run a Democratic administration" and includes a proposal for health care reform, AP/Newsweek reports. According to AP/Newsweek, the center calls for refundable tax credits to help some U.S. residents cover the cost of health insurance premiums. In addition, the center calls for a requirement that all residents obtain health insurance or pay a fee to help finance any health care they would require in the event of illness or injury. Basic Books plans to release the "Progressive Blueprint" in the days after the presidential election in the event that Obama wins (Babington, AP/Newsweek, 10/30).
  
  
• Congress on presidential agenda: Three "main factions are emerging" in Congress with advice for Obama on his legislative agenda in the event that he wins the presidential election, the Wall Street Journal reports. According to the Journal, one group, led by "old bull" liberals, seeks to address a number of "big-ticket issues," such as universal health care, early in an Obama presidency. A second group, which includes fiscally conservative Democrats, "say the money for Sen. Obama's ambitious agenda simply isn't there" and argue that "one of the first acts of the next Congress should be approving a bipartisan commission to tackle the deficit and the growth of entitlements, such as Medicare and Medicaid," the Journal reports. A third group, which "could be labeled the middle-ground pragmatists," says Obama "should move quickly on a few items with proven bipartisan support," such as an expansion of SCHIP funded by an increase in the federal tobacco tax and increased federal funding for embryonic stem cell research, according to the Journal (Weisman, Wall Street Journal, 10/30).
  
  
• Economic issues: The next president will face a "host of acute economic problems," such as health care, on a "scale not seen since the 1930s," Reuters reports. According to Reuters, both Obama and McCain cite "bringing down high health care costs and reforming the health insurance system as an economic priority" (Reuters, 10/30).
  
  
• Examination of health care proposals: The Dallas Morning News on Thursday examined the Obama and McCain health care proposals. In addition, the Morning News examined the accuracy of statements that Obama and McCain have made about the proposals of their opponents (Dallas Morning News, 10/30).
  
  
• Rep. Michael Burgess (R-Texas): Burgess has traveled to 10 states to promote the McCain health care proposal, the Morning News reports. According to the Morning News, Burgess, an obstetrician, is the only physician on the McCain team of health care advisers and would become "a White House insider and a go-to lawmaker on health care issues" in the event that McCain wins the presidential election (Michaels, Dallas Morning News, 10/30).

Opinion Pieces
Several newspapers recently published opinion pieces that addressed health care issues in the presidential election. Summaries appear below.

• Ruth Faden/Madison Powers, Baltimore Sun: "Mr. McCain's and Mr. Obama's health plans are based on very different moral visions of what makes a health care system fair, and this difference offers voters a real basis for choice," Faden, director of the Johns Hopkins University Berman Institute of Bioethics, and Powers, director of the Kennedy Institute of Ethics at Georgetown University, write in a Sun opinion piece. The authors write, "What Mr. McCain sees as unfair about our current system is how the costs of health care are financed," which "is right," but "unfairness in financing is only a part of what is morally wrong with our health care system." Obama "sees as the most unfair about the system ... the profound disadvantages that people without access to adequate health care experience," the authors add. According to the authors, "when it comes to fairness, McCain gets it half right, but Obama gets it more right" (Faden/Powers, Baltimore Sun, 10/30).
  
  
• Al Franken, St. Paul Pioneer Press: "I like Obama's approach, and I would proudly support it," but "I'll be blunt: I think McCain's health care proposal would be a disaster for Minnesota families," Franken, a U.S. Senate candidate from Minnesota, writes in a Pioneer Press opinion piece. According to Franken, the Obama proposal would ensure that, "if you have health insurance that works for you ... you get to keep it," reduce costs "by as much as $200 billion a year" and "guarantee that insurance companies cover pre-existing conditions and preventive health measures." Meanwhile, under the McCain proposal, "as many as 580,000 Minnesotans could outright lose their employer-sponsored health care, and we'd all be at the mercy of the insurance companies," Franken writes (Franken, St. Paul Pioneer Press, 10/29).
  
  
• Clive Crook, Atlantic: "I think McCain's health credit is good as far as it goes, but it does not go nearly far enough," Atlantic columnist Crook writes. Meanwhile, "Obama's plan would expand coverage much more, and it seems to me that this should be a key goal," Crook writes. He adds, "However, the fact remains that McCain's plan would put more disposable income (net of taxes and health care outlays) in the pockets of most middle-income voters" (Crook, Atlantic, 10/29).
  
  
• Jonah Goldberg, Chicago Tribune: "Obama prefers the word 'progressive' to 'liberal' because it makes it sound like he's shedding old liberal ideas" but, "if he is, it's only to embrace older ones," National Review Online editor Goldberg writes in a Tribune opinion piece. Goldberg writes, "Officially, Obama says he is not advocating single-payer health care" because that "would seem too un-moderate," but Obama in 2003 "told the AFL-CIO, 'I happen to be a proponent of a single-payer universal health care program. ... But as all of you know, we may not get there immediately. Because we have to take back the White House.'" Goldberg adds, "Only in a country of amnesiacs could one claim that socialized medicine is a 'new idea'" (Goldberg, Chicago Tribune, 10/30).
  
  
• Scott Bahr, Detroit News: "I don't want employer-provided health care, and neither should you," because of the cost Bahr, a Michigan resident, writes in a News opinion piece. The "John McCain health care plan would help save money," he writes, adding, "I shudder to think how bad" health insurance costs "would be in a national plan, yet this is exactly what Barack Obama supports." McCain would provide the average employee with the "same health care with a little extra income and virtually no change in taxes," Bahr writes, adding, "Obama's plan spreads costs, while McCain's plan actually cuts costs" (Bahr, Detroit News, 10/30).
  
  
• Charles Roehrig/George Miller, Detroit News: Neither Obama nor McCain has announced a health care proposal that would "create a financially sustainable system that provides affordable, high quality care for decades to come," Roehrig, vice president of the Altarum Institute, and Miller, a senior analyst at the institute, write in a News opinion piece. They cite the need to "improve the health system in ways that reduce cost growth and demonstrably increase the value of existing spending" and "address stagnant incomes at the lower end of the income scale." According to the authors, the next president "will find resistance to expensive new programs," but the "problem of unaffordable health insurance will only get worse." They conclude, "Understanding the importance of creating a truly sustainable health system will help the next president make difficult trade-offs in difficult times" (Roehrig/Miller, Detroit News, 10/30).
  
  
• Elaine Rose/Mo West, Seattle Post-Intelligencer: The McCain health care proposal, which would "deregulate the health care industry," is "worse for women" than the Obama plan, Rose, CEO of Planned Parenthood VOTES Washington, and West, chair of the group, write in a Post-Intelligencer opinion piece. Under the McCain proposal, "30 million women who suffer from a pre-existing condition could lose their coverage," and the plan would eliminate "important state insurance requirements aimed at protecting women's access to basic health needs," the authors write. They write, "After the recent financial catastrophe, we've all seen just how disastrous an unregulated and excessively greedy banking system has been for our country," adding, "We can't let the same thing happen to health care -- it's just too important" (Rose/West, Seattle Post-Intelligencer, 10/29).

Broadcast Coverage
WAMU's "The Diane Rehm Show" on Thursday included a comparison of proposals from Obama and McCain on health care and other issues. The segment includes comments from Karen Tumulty, a reporter for Time Magazine; Greg Ip, U.S. economics editor for The Economist; and Warren Strobel, senior correspondent for foreign affairs at McClatchy's Washington, D.C. bureau (Rehm, "The Diane Rehm Show," WAMU, 10/30).

In addition, Washington Post reporter Amy Goldstein on Wednesday in a Post Live Discussion addressed the Obama and McCain health care proposals (Goldstein, Washington Post Live Discussion, 10/29).

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MEDICAID

5.  National Governors Association Calls for Medicaid Funding To Be Included in Potential Economic Stimulus Package

     On Wednesday, New York Gov. David Paterson (D), representing the National Governors Association, called for a new economic stimulus package that would provide "direct and immediate fiscal relief" for states, including a 5% increase in federal Medicaid matching payments for two years, CongressDaily reports (Cohn, CongressDaily, 10/29). Paterson at a House Ways and Means Committee hearing said that a temporary increase in the Federal Medical Assistance Percentage should be provided to "states hardest hit by the current economic crisis." In addition, he called for a new stimulus package to include a moratorium on a regulation that reduces Medicaid payments for outpatient clinics.

Paterson, who noted that his own state faces a $47 billion budget shortfall over the next four years, said that "governors can only cut so much before we begin to jeopardize our fundamental responsibilities to our constituents," such as "providing health care for the most vulnerable" (Reichard, CQ HealthBeat, 10/29).

According to CongressDaily, "House Democratic leaders appear to be moving toward bringing a $100 billion economic stimulus package to the floor during a lame-duck session the week of Nov. 17." Aides said a package in that price range was discussed on Tuesday and leaders were considering including Medicaid funds, an extension of unemployment benefits, expanding food stamp spending and funding for infrastructure projects (Bourge, CongressDaily, 10/29).

Republicans showed signs of "pushing back" against plans for the economic stimulus package, CQ HealthBeat reports. South Carolina Gov. Mark Sanford (R) testified that a $150 billion economic stimulus package would "dangerously encourage even more growth in governmental programs like Medicaid, which in state budgets across the nation already grew 9.5% per year over the last decade -- certainly unsustainable in our state." He added, "There may be better routes to recovery than a blanket bailout, including offering states like mine more in the way of flexibility and freedom from federal mandates instead of a bag of money with strings attached."

Committee ranking Republican Jim McCrery (La.) said, "We have to a great extent blurred lines between federal and state" responsibilities, adding, "What many are suggesting here today is that we blur these lines further" (CQ HealthBeat, 10/29). Committee Chair Charles Rangel (D-N.Y.) said that "there is no $150 billion package and we will not have any package at all unless the president agrees" (Cohn, CongressDaily, 10/29).

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PRESCRIPTION DRUGS

6.  Internal Documents Indicate Two FDA Officials Objected To Rules Aimed at Pre-Empting Lawsuits

     Two FDA officials objected to rules recently issued by the agency that sought to limit the ability of consumers to file product liability lawsuits against pharmaceutical companies in state courts, according to internal documents released on Wednesday by House Oversight and Government Reform Committee Chair Henry Waxman (D-Calif.), the Wall Street Journal reports (Mundy, Wall Street Journal, 10/30).

In 2006 and 2008, FDA issued rules that increased agency responsibility for medication labels in support of pre-emption, a legal principle under which federal laws supersede state laws. Supporters maintain that FDA approval of medication labels pre-empts the ability of consumers to file lawsuits against pharmaceutical companies under state product liability laws (Armstrong, CQ HealthBeat, 10/29).

According to the documents, two FDA officials in memos said that FDA approval of medication labels are not completely reliable or based on full disclosure of safety risks by pharmaceutical companies. The "internal documents also revealed that the White House played a significant role in drafting the industry-friendly rules" in support of pre-emption, CongressDaily reports (CongressDaily, 10/29).

Memos
John Jenkins, director of the FDA Office of New Drugs, in a 2003 e-mail wrote, "Much of the argument for why we are proposing to invoke pre-emption seems to be based on a false assumption that the FDA-approved labeling is fully accurate and up-to-date" (Favole, Dow Jones, 10/29). He added, "We know that such an assumption is false" (CQ HealthBeat, 10/29). In addition, he wrote, "It is a gross overstatement of reality" that pharmaceutical companies would disclose all of the safety risks of new medications (Savage, Los Angeles Times, 10/30).

In a 2003 memo, FDA associate director for policy Jane Axelrad wrote, "We rarely find ourselves in situations" in which pharmaceutical companies "want to disclose more risk information than we think is necessary." She added, "To the contrary, we usually find ourselves dealing with situations where sponsors want to minimize the risk information" (Freking, AP/Boston Globe, 10/29). Axelrad also wrote that pre-emption "is not, as it purports to be, consistent with the agency's role in protecting the public health."

The documents likely will prompt Waxman and other congressional Democrats who oppose pre-emption to draft legislation "reversing the Bush administration's pre-emption policy," the Journal reports. Waxman released the documents in advance of a case on the pre-emption that the Supreme Court plans to hear on Monday. The case, Wyeth v. Levine, could determine whether consumers can file product liability lawsuits against pharmaceutical companies in state courts (Wall Street Journal, 10/30).

Comments
Brian Wolfman, director of Litigation Group at Public Citizen, said that the documents are "devastating to the government's case." He added, "They show that the nonpolitical people -- the actual experts in the drug-approval process -- didn't agree with the approach of deferring to the companies."

Alliance for Justice President Nan Aron called the efforts by the Bush administration to "protect powerful corporations from liability at the expense of the safety of American consumers ... unconscionable."

According to a statement released by FDA, "FDA encourages and expects a robust exchange of ideas on matters of public health and public policy." The statement added, "As in any organization, there is rarely unanimity of opinion. In proposing the rules, FDA carefully considered dissenting viewpoints. Many employees of FDA participated in the development and review of the rules" (Los Angeles Times, 10/30).

Levine Profile
USA Today on Thursday profiled Diana Levine, the plaintiff in Wyeth v. Levine, and examined the issue of pre-emption. According to USA Today, the "outcome of the case could affect thousands of potential lawsuits by consumers against drug companies each year" (Appleby, USA Today, 10/30).

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7.  Health Insurers Push Physicians To Prescribe Generic Drugs

     The AP/Houston Chronicle on Wednesday examined how health insurers "are allowed to push doctors toward cheaper prescriptions, frequently by offering the physician a form of bonus, a cut from the savings that insurance companies get when doctors prescribe generic drugs." The practice represents "the flip side of a concern about corporate influence in the doctor's office that's been criticized -- often stridently -- when the pharmaceutical industry entices doctors to prescribe brand-name drugs."

Last year, the American Medical Association classified incentives as kickbacks and warned that physicians who accept rewards for prescribing generic drugs could face criminal and civil liability under federal statutes. Some states are considering legislation that would increase scrutiny of insurers' incentives. A bill pending in Massachusetts would regulate incentive plans between insurers and providers, while a Michigan proposal would ban financial incentives but allow insurers to compensate physicians for time spent evaluating whether a switch to generics would be best for a patient. New York state Sen. Jeffrey Klein (D) introduced legislation that would prevent insurers from offering incentives, and a grandfather clause would require HMOs to continue providing brand-name drugs to patients who benefit from them.

According to the AP/Chronicle, "Insurers say they encourage generics because it keeps consumer costs down when health care expenses are spiking." In addition, insurers say that prescribing generics could help people maintain their drug regimens because some patients do not consistently take costly brand-name drugs to save money. Robert Zirkelbach, a spokesperson for America's Health Insurance Plans, said, "Health plans are not mandating to physicians what to prescribe to patients," adding, "They are providing incentives to encourage greater use of generic drugs" (Bauman, AP/Houston Chronicle, 10/29).

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STATE WATCH

8.  D.C. Councilmember Says Delay of Low-Income Coverage Program Needed To Help Shore Up Funds Amid Financial Crisis

     The Washington, D.C., councilmember who proposed a plan that would provide health insurance to thousands of uninsured district residents said on Tuesday that he wants to delay the program by at least a year to allow the district to create a $20 million cash reserve amid the recent economic downturn, the Washington Post reports (Nakamura, Washington Post, 10/29). The Healthy D.C. bill, sponsored by David Catania (I), would provide coverage for about 25,000 uninsured residents who are ineligible for Medicaid and the D.C. HealthCare Alliance. Under the program, residents with incomes lower than 200% of the federal poverty level would receive subsidies, paying monthly premiums between $20 and $100, depending on income (Kaiser Daily Health Policy Report, 4/1).

Catania said a cash reserve must be created to prepare for an expected decline in revenue, which would increase the number of people seeking coverage under the Alliance, a safety-net for low-income residents. He also has been critical of revenue estimates made by D.C. CFO Natwar Gandhi, who last month said that the district faces a $131 million revenue shortfall for fiscal year 2009. Catania said that estimate is too low because financial conditions are likely to worsen. Gandhi disagreed with Catania's estimates and notes that the $700 billion bailout of Wall Street firms passed by Congress will help stabilize the economy.

Catania said, "No one looks forward to making reductions," but the downturn "means we have to take action that is more aggressive than we'd like but that the times require." He said other initiatives, such as a planned increase in Medicaid provider reimbursements and a proposal to add medical doctors to public schools, also would have to be delayed. Mayor Adrian Fenty on Tuesday said that he will issue an executive order to reduce spending throughout the district government by $52 million (Washington Post, 10/29).

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OPINION

9.  Editorial Says Emergency Department Overcrowding Needs To Be Addressed by Increasing Funding, Resources; Covering Uninsured

     A recent study that calls into question the "widely held belief that uninsured people are clogging the nation's" emergency departments to receive no-cost care for minor ailments "leaves another troublesome implication: that many uninsured patients are simply going without needed care until they become so sick that they can't stay away," a New York Times editorial states. According to the editorial, "There are many causes of emergency room crowding," including ED closures, a shortage of primary care physicians, a "concomitant rise in the number of patients turning to emergency rooms and a shortage of inpatient beds into which the sickest patients can be moved." The editorial continues, "These problems need to be solved with an infusion of money and resources," adding that it also "remains critical to provide health coverage for some 45 million uninsured Americans." The editorial states, "The new study suggests that many of them may not 'just go to an emergency room' for the care they need" (New York Times, 10/30).

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RECENT RELEASES IN HEALTH POLICY

10.  Perspective Examines Wasteful Spending in the U.S. Health Care System

     "Waste, We Know You Are Out There," New England Journal of Medicine: In the perspective, Henry Aaron, a senior fellow at the Brookings Institution, discusses what is meant by wasteful spending in regard to health care, whether the U.S. has "the means to curtail it" and how quickly savings could be realized from reducing waste. He also discusses several ways to cut spending on low-benefit, high-cost care and other ideas to control health care spending and achieve savings (Aaron, NEJM, 10/30).