Prometheus 6

Lobbying on all sides has been intense. The New England Promotional Products Association even punctuated its appeal to lawmakers with a gift.

"We don't feel making a pen or coffee mug illegal is going to accomplish their goals," said Stephen Monahan, the products association's president.

The mugs handed out to Massachusetts lawmakers, he said, were not intended to influence their opinions, just to remind them that more than 3,500 of the association's members are Massachusetts voters who depend on this industry for a livelihood.

I feel your pain, but the fact that Big Pharma is modifying their voluntary code means they know their ass is exposed. And we know that voluntary code will go right out the window as soon as it impinges on profitability...which is to say, no more than 48 hours after its announcement. After all, there's no penalty for ignoring a voluntary measure.

I'm hoping we can toss voluntary "regulation" on E.J. Dionne's pile of collapsed conservative concepts.

Drug industry tightens rules on gift-giving
Trade group is opposing Mass. effort to ban practice
By Kay Lazar, Globe Staff  |  July 11, 2008

The trade association for drug companies announced yesterday a tightening of its voluntary code restricting industry gifts to doctors, even as the association has been forcefully lobbying against a tougher ban that is likely to be debated in the Massachusetts House next week.

The Pharmaceutical Research and Manufacturers of America said its guidelines prohibit drug company sales representatives from handing out pens, mugs, and other tokens emblazoned with company or product logos, and also disallow restaurant meals. But the rules still allow salespeople to cater free lunches in doctors' offices and hospitals, which they use to get access to doctors and make their sales pitches. Companies would still be able to pay doctors consulting and speaking fees, which industry critics say is the fastest-growing category of drug marketing. And the code relies on the industry to police itself.

The proposed state law, already unanimously ap proved in the Senate, would ban any gifts of value to doctors. That includes entertainment, meals, travel, and subscriptions. Drug and medical-device companies would have to report to the Department of Public Health any payments to doctors for speaking and consulting, and that information would be posted on the agency's website.

The F.D.A. does not test experimental medicines but relies on drug makers to report the results of their own tests completely and honestly. Even when companies fail to follow agency rules, officials rarely seek to penalize them. “These are scientists, not cops,” said David Vladeck, a professor at Georgetown Law School.

Last month, at a trial over the schizophrenia drug Zyprexa, Dr. John Gueriguian, a scientist who worked at the F.D.A. for two decades, testified that the agency did not always ask for strong warnings even if it believed a drug was risky. Companies typically oppose warnings, and the agency knows it must compromise on its requests or face years of delay, Dr. Gueriguian said.

“We at the F.D.A. know what we can obtain and we cannot obtain,” Dr. Gueriguian said. “We have many, many problems, and we have a management system — what we can’t obtain we will not ask.” 

Drug Makers Near an Old Goal: A Legal Shield
By GARDINER HARRIS and ALEX BERENSON

For years, Johnson & Johnson obscured evidence that its popular Ortho Evra birth control patch delivered much more estrogen than standard birth control pills, potentially increasing the risk of blood clots and strokes, according to internal company documents.

But because the Food and Drug Administration approved the patch, the company is arguing in court that it cannot be sued by women who claim that they were injured by the product — even though its old label inaccurately described the amount of estrogen it released.

This legal argument is called pre-emption. After decades of being dismissed by courts, the tactic now appears to be on the verge of success, lawyers for plaintiffs and drug companies say.

The Bush administration has argued strongly in favor of the doctrine, which holds that the F.D.A. is the only agency with enough expertise to regulate drug makers and that its decisions should not be second-guessed by courts. The Supreme Court is to rule on a case next term that could make pre-emption a legal standard for drug cases. The court already ruled in February that many suits against the makers of medical devices like pacemakers are pre-empted.

Merck officials stressed that the agency’s inquiry was based on reports, not clinical studies, which are the standard tool for evaluating drug safety. The company said none of the 11,000 patients enrolled in 40 Singulair trials had committed suicide.

U.S. to Study Drug for Suicide Links
By THE ASSOCIATED PRESS

WASHINGTON (AP) — The Food and Drug Administration said Thursday that it was investigating a possible link between Merck’s best-selling drug Singulair and suicide.

The agency said it was reviewing a handful of reports involving mood changes, suicidal behavior and suicide in patients who had taken Singulair, the popular allergy and asthma drug.

Merck has updated the drug’s labeling four times in the last year to include information on a range of reported side effects, including tremors, anxiousness, depression and suicidal behavior.

You'd think that those lower costs abroad would mean worse care. (You'd certainly think that if you listened to GOP candidates sneering at the British, French or Canadian systems.) But the closer one looks, the more unexceptional -- and often downright mediocre -- U.S. care looks....

Indeed, by some measures, U.S. health care looks downright lousy. A six-country study by researchers at the Commonwealth Fund, a health-care think tank with a generally liberal bent, concludes that the United States "scores particularly poorly on its ability to promote healthy lives, and on the provision of care that is safe and coordinated." Meanwhile, a recent analysis of 19 rich nations by Ellen Nolte and C. Martin McKee of the London School of Hygiene and Tropical Medicine found that the United States has the highest rate of "amenable mortality" before age 75 (the odd term of art for deaths that could have been prevented with timely care) -- and that we're falling farther behind.

Let's Try a Dose. We're Bound to Feel Better.
By Jacob S. Hacker
Sunday, March 23, 2008; B01

"Socialized medicine" is the bogeyman that just won't die. The epithet has been hurled at every national health plan since the New Deal -- even Medicare, which critics warned would strip Americans of their freedom.

And now it's back. Republicans from President Bush on down have invoked the specter of socialism in denouncing Democrats' attempts to expand publicly funded health insurance for children. Erstwhile GOP presidential contenders Rudy Giuliani and Mitt Romney lambasted the health plans of the leading Democratic candidates for mimicking "the socialist solution they have in Europe" (Giuliani) and trying to impose "a European-style socialized medicine plan" (Romney). The presumptive Republican nominee, Sen. John McCain, hasn't used the S-word yet, but after sewing up the nomination in early March, he criticized Democrats for intending "to return to the failed, big-government mandates of the '60s and '70s to address problems such as the lack of health-care insurance for some Americans."

But she moves to weightier matters in assessing the directions in which heavy drug dependence is leading Americans. First of all there are the business strategies that have created illnesses out of what used to be facts of life, labeled them as syndromes, and have hooked customers into long-term use of medication to cure them. (Detrol, the obnoxiously advertised cure for what its manufacturer calls “overactive bladder,” is a case in point, especially since it can cause hallucinations that resemble symptoms of Alzheimer’s disease.) Second, there are the economics of creating chronic consumers for marginally necessary drugs.

Irate as she is that in a period (1980-2003) when Americans doubled what they spent on cars they increased their spending on prescription drugs by 17 times, Ms. Petersen steps back to consider the long-term consequences of this shift in consumption. She notes that the first generation of children raised in front of ubiquitous, sunny drug-company advertisements (which became legal in 1997) has acquired the notions that prescription pills fix everything, and that they are less dangerous than street drugs. Then, looking to the elderly, she points out that increasing numbers of drugs are accumulating in these patients, with little regard for the consequences.

The Case for Another Drug War, Against Pharmaceutical Marketers’ Dirty Tactics
By JANET MASLIN 

By the time Melody Petersen gets around to interviewing Iowa’s state nosologist near the end of “Our Daily Meds,” the facts that she cites don’t even sound that grim. The nosologist’s job is to catalog Iowa’s deceased according to cause of death. He processes about 27,000 death certificates a year. And by his reckoning there were only five deaths caused by adverse reactions to prescription drugs in 2002. That low figure is jarringly out of whack with Ms. Petersen’s investigative reporting in an angrily illuminating book on drug-related corporate malfeasance and patient peril.

“Could drugs be killing people but escaping all blame, leaving them to harm even more Americans until someone, finally, catches on?” Ms. Petersen asks. Given the information that her book uncovers, this a purely rhetorical question. Her study cites reckless and questionable behavior in all aspects of drug companies’ research and marketing ploys, even if much of this is familiar territory. It has been explored by earlier crusaders (notably Marcia Angell in “The Truth About the Drug Companies”) and in Ms. Petersen’s own journalism. She spent four years as a reporter covering the drug industry for The New York Times. 

Previous studies have shown that pill size and color also affect people’s perceptions of effectiveness. In one, people rated black and red capsules as “strongest” and white ones as “weakest.”...

“It’s all about expectations,” said the lead researcher, Dan Ariely, a behavioral economist at Duke...“When you’re expecting pain relief, you’re secreting your own opioids,” Dr. Ariely added. “And when you get it on discount, you doubt it, and your body doesn’t react as well.”

More Expensive Placebos Bring More Relief
By BENEDICT CAREY

In marketing as in medicine, perception can be everything. A higher price can create the impression of higher value, just as a placebo pill can reduce pain.

Now researchers have combined the two effects. A $2.50 placebo, they have found, works better one that costs 10 cents.

The finding may explain the popularity of some high-cost drugs over cheaper alternatives, the authors conclude. It may also help account for patients’ reports that generic drugs are less effective than brand-name ones, though their active ingredients are identical.

Here's a question for you, my Billary-supporting friend. 

But while it’s easy to see how the Clinton plan could end up being eviscerated, it’s hard to see how the hole in the Obama plan can be repaired. 

Can you see how the Obama plan could end up being eviscerated?

If Mrs. Clinton gets the Democratic nomination, there is some chance — nobody knows how big — that we’ll get universal health care in the next administration. If Mr. Obama gets the nomination, it just won’t happen.

It won't happen no matter who wins.

You may get universal health insurance. Neither offers universal health care. I really wish alla youse would stop twisting that.

Cholesterol Drug Bombs

There have long been suspicions, but it was still very disturbing to learn this week that a heavily promoted cholesterol-lowering drug had flunked a clinical trial of its effectiveness in reducing fatty deposits in arteries. The two companies that reap billions from the drug had been cynically sitting on the results for more than a year.

The drug, Zetia, and a combination pill that contains it, Vytorin, are made by Merck and Schering-Plough and used by millions of patients. They generated more than $5 billion in sales last year. The companies sponsored a clinical trial of the drug’s effectiveness in hopes that positive results would strengthen their marketing efforts.

"That finding suggests that the samples were a marketing tool and not a safety net because the poor and uninsured patients were not finding their way to where the samples were," Cutrona said....

..."Clearly, free samples often lead to improved quality of life for millions of Americans, regardless of their income" [Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America, said in a statement]

Johnson called free samples a safety net for many uninsured and low-income patients in a letter to the editor that was published in 2006 in The New York Times.

Drug sample distribution system faulted
Study finds most of free products go to the insured
By Elizabeth Cooney, Globe Correspondent  |  January 3, 2008

Free drug samples are more likely to go to wealthy and insured people than to poor or uninsured Americans, according to a study by Boston-area doctors that conflicts with the view that giving away prescription medications forms a safety net for low-income patients.

Fewer than one-third of all people who received samples in a 32,000-person, nationally representative survey had low incomes, and fewer than one-fifth who got the free drugs were uninsured at any point in 2003, the year analyzed by researchers at Cambridge Health Alliance and Harvard Medical School. Low income was defined as less than 200 percent of the federal poverty line.

The draft guidance "would open the door to abusive marketing practices that will jeopardize safety, undermine public health, and lead to an increase in unapproved uses of powerful drugs," Waxman wrote.

Companies would be less likely to conduct definitive scientific studies and seek formal FDA approval for alternative uses of drugs and devices if they could promote and profit from off-label uses anyway, Waxman contended. He said the proposal could grant undue influence to incomplete or distorted studies, some of them industry-funded. And he pointed to several high-profile cases in which drugs such as Vioxx and Celebrex were trumpeted in flawed journal articles that either underreported dangers or overstated benefits.

"While there may need to be a balance between First Amendment and protection of the public health," Waxman wrote, "the answer is not to open the door to unrestricted dissemination of potentially questionable information about drug safety and effectiveness."

FDA Considers Easing Curbs on Drug Makers
Research on Off-Label Use Could Be Sent to Doctors
By Christopher Lee
Washington Post Staff Writer
Saturday, December 1, 2007; A04

The Food and Drug Administration is considering allowing pharmaceutical makers to provide doctors with medical journal studies of unapproved uses for drugs, a move critics say would undermine long-standing restrictions on marketing medicines for "off-label" purposes.

Under a draft "guidance" prepared by the FDA, drug and medical device manufacturers could distribute unabridged reprints of peer-reviewed research from reputable medical journals as long as the articles were not written, edited or otherwise "significantly influenced" by the manufacturers or people with financial ties to them. No other promotional materials could be attached to the reprints, which would have to be labeled as describing uses for the products that have not been approved by the FDA.

Phillip J. Blando, a political strategist who advises insurance and biotechnology companies, said the health care contributions to Democratic candidates were “smart politics.”

“For many people in the industry,” Mr. Blando said, “these contributions are a defensive measure. Health care is the No. 1 domestic policy issue, and they want access, a seat at the table.” ...

It also underscores the industry’s frantic effort to influence the candidates, as Democrats push their proposals to address what many polls show is a top concern among voters.

Health Sector Puts Its Money on Democrats
By RAYMOND HERNANDEZ and ROBERT PEAR

WASHINGTON, Oct. 28 — In a reversal from past election cycles, Democratic candidates for president are outpacing Republicans in donations from the health care industry, even as the leading Democrats in the field offer proposals that have caused deep anxiety in some of its sectors.

Hospitals, drug makers, doctors and insurers gave candidates in both parties more than $11 million in the first nine months of this year, according to an analysis of campaign finance records done for The New York Times by the Center for Responsive Politics, an independent group that tracks campaign finance.

Collectively the companies account for about 90 percent of the 1.3 million Medicare beneficiaries enrolled in private fee-for-service plans, Block said.

Congressional investigators said in hearings last month that some agents seeking to cash in on high commissions have enrolled the mentally incompetent, impersonated Medicare representatives and misrepresented provisions of the plans....

"This isn't really enforcement," said Abby L. Block, director of the agency's Center for Beneficiary Choices. "This is a voluntary agreement. In terms of the conditions we've put forward, they are just what we would consider to be good business management."

Insurers to Halt Medicare Plan Sales
By Christopher Lee
Washington Post Staff Writer
Saturday, June 16, 2007; A07

Seven insurance companies have agreed to stop marketing private Medicare plans temporarily amid complaints that agents used illegal or unethical sales tactics, Medicare officials announced yesterday.

"In this case, commercial interests took precedence over the interests of the private citizens of New Hampshire," Rosenwald said. "This is like letting a drug rep into an exam room and having them eavesdrop on a private conversation between a physician and a patient."

Which has happened, by the way.

The concerns are not merely about privacy. Proponents say using such detailed data for drug marketing serves mainly to influence physicians to prescribe more expensive medicines, not necessarily to provide the best treatment....

The American Medical Association...makes millions of dollars each year by helping data-mining companies link prescribing data to individual physicians. It does so by licensing access to the AMA Physician Masterfile, a database containing names, birth dates, educational background, specialties and addresses for more than 800,000 doctors.

Doctors, Legislators Resist Drugmakers' Prying Eyes
By Christopher Lee
Washington Post Staff Writer
Tuesday, May 22, 2007; A01

Seattle pediatrician Rupin Thakkar's first inkling that the pharmaceutical industry was peering over his shoulder and into his prescription pad came in a letter from a drug representative about the generic drops Thakkar prescribes to treat infectious pinkeye.

In the letter, the salesperson wrote that Thakkar was causing his patients to miss more days of school than they would if he put them on Vigamox, a more expensive brand-name medicine made by Alcon Laboratories.

"My initial thought was 'How does she know what I'm prescribing?' " Thakkar said. "It feels intrusive. . . . I just feel strongly that medical encounters need to be private."

Federal laws already bar drug companies from paying doctors to prescribe medicines in pill form. That prohibition should be extended to injected and intravenous medicines.

The Danger in Drug Kickbacks

The explosion in the use of three anti-anemia drugs to treat cancer and kidney patients illustrates much that is wrong in the American pharmaceutical marketplace. Thanks to big payoffs to doctors, and reckless promotional ads permitted by lax regulators, the drugs have reached blockbuster status. Now we learn that the dosage levels routinely injected or given intravenously in doctors’ offices and dialysis centers may be harmful to patients.

Costs Grow for Common Medicare Drugs
Price Increase in Prescription Program Is Twice That Seen in Wholesale Rates
By Jonathan Weisman
Washington Post Staff Writer
Sunday, May 13, 2007; A10

After some initial success containing drug prices, private insurers in the new Medicare prescription drug program may be losing their leverage over drug manufacturers as they try to hold down medicine costs for seniors and the federal government, House investigators have found.

Prices for 10 of the most prescribed brand-name medications have shot up an average of 6.8 percent since December under Medicare private insurance plans, while wholesale prices for the same drugs have risen just 3 percent, House Oversight and Government Reform investigators say. The cost of a month's supply of cholesterol-controlling Lipitor had climbed 9.6 percent, to $84.27 in mid-April, from $76.91 in mid-December. Over the same time, list prices climbed 5 percent.

[E]xperienced drug abusers and novices, including teenagers, soon discovered that chewing an OxyContin tablet — or crushing one and then snorting the powder, or injecting it with a needle — produced a high as powerful as heroin. OxyContin is a pure, high-strength version of a long-used narcotic, oxycodone.

By 2000, parts of the United States, particularly rural areas, began to see soaring rates of addiction and crime related to use of the drug.

At a news conference Thursday in Roanoke, Va., John L. Brownlee, the United States attorney for the Western District of Virginia, said the impact of Purdue’s marketing of OxyContin had resulted in rising crime rates, teenage drug addiction, deaths and other problems.

“The results of Purdue’s crimes were staggering,” he said.

Narcotic Maker Guilty of Deceit Over Marketing
By BARRY MEIER

ABINGDON, Va., May 10 — The company that makes the painkiller OxyContin and three of its current and former executives pleaded guilty Thursday in federal court here to criminal charges that it had misled doctors and patients when it claimed the drug was less likely to be abused than traditional narcotics.

The company, Purdue Pharma, agreed to pay $600 million in fines and other payments to resolve the criminal charge of “misbranding” the product, one of the largest amounts ever paid by a drug company in such a case.

...this is evil. That's all I could think of.

From 2000 to 2005, drug maker payments to Minnesota psychiatrists rose more than sixfold, to $1.6 million. During those same years, prescriptions of antipsychotics for children in Minnesota’s Medicaid program rose more than ninefold.

Those who took the most money from makers of atypicals tended to prescribe the drugs to children the most often, the data suggest. On average, Minnesota psychiatrists who received at least $5,000 from atypical makers from 2000 to 2005 appear to have written three times as many atypical prescriptions for children as psychiatrists who received less or no money.

Psychiatrists, Children and Drug Industry’s Role
By GARDINER HARRIS, BENEDICT CAREY and JANET ROBERTS

When Anya Bailey developed an eating disorder after her 12th birthday, her mother took her to a psychiatrist at the University of Minnesota who prescribed a powerful antipsychotic drug called Risperdal.

Created for schizophrenia, Risperdal is not approved to treat eating disorders, but increased appetite is a common side effect and doctors may prescribe drugs as they see fit. Anya gained weight but within two years developed a crippling knot in her back. She now receives regular injections of Botox to unclench her back muscles. She often awakens crying in pain.

Isabella Bailey, Anya’s mother, said she had no idea that children might be especially susceptible to Risperdal’s side effects. Nor did she know that Risperdal and similar medicines were not approved at the time to treat children, or that medical trials often cited to justify the use of such drugs had as few as eight children taking the drug by the end.

Just as surprising, Ms. Bailey said, was learning that the university psychiatrist who supervised Anya’s care received more than $7,000 from 2003 to 2004 from Johnson & Johnson, Risperdal’s maker, in return for lectures about one of the company’s drugs.

Last year, Senator Patrick Leahy sponsored a bill to ensure that medical technologies developed at federally funded labs would be available not just to branded drug makers but also to low-cost generic drug makers serving developing countries.

I've long said

If two stamps, an envelope and a postcard are given to a lab in support of pharmaceutical research, then compound should be in the public domain.

My reasoning is, the risk pharmaceutical companies undertake is in creating the processes whereby the drug is produced, packaged and distributed safely (I include testing in this). They are entitled to a process patent. But in most cases the company neither discovered the compound nor ascertained its primary effects.

...because I'd like Americans to be able to afford the drugs, too.

Biotech: Not just for the rich
May 8, 2007

BEHIND THE vibrancy of the life sciences industry so visible at the 2007 BIO convention this week in Boston is a sobering statistic from the World Health Organization: Each year, 10 million people in poor nations die because they lack access to existing medicines or vaccines. In his keynote address yesterday, Michael J. Fox, the actor and founder of a Parkinson's disease research foundation, said that of the 30,000 known human diseases, there are treatments for just 10,000. Many of the diseases without treatments afflict residents of resource-poor countries, which draw little interest from drug makers.

Cefquinome's seemingly inexorable march to market shows how a few words in an obscure regulatory document can sway the government's approach to protecting public health....

...In the mid-1990s, overriding the objections of public health experts from the Centers for Disease Control and Prevention (CDC), the drug agency approved the marketing of two drugs, Baytril and SaraFlox, for use in poultry. Both are fluoroquinolones, a class of drugs important for their ability to fight the bioterror bacterium that causes anthrax and a food-borne bacterium called campylobacter, which causes a serious diarrheal disease in people.

Before long, doctors began finding fluoroquinolone-resistant strains of campylobacter in patients hospitalized with severe diarrhea. When studies showed a link to poultry, the FDA sought a ban. But while Abbott Laboratories, which made SaraFlox, pulled its product, Baytril's manufacturer, Bayer Corp., pushed back.

"They fought this tooth and nail. It took years," said Kirk Smith, an epidemiologist at the Minnesota Department of Health.

Finally, late in 2005, Bayer gave up, but not before fluoroquinolone resistance had spread even further.

FDA Rules Override Warnings About Drug
Cattle Antibiotic Moves Forward Despite Fears of Human Risk
By Rick Weiss
Washington Post Staff Writer
Sunday, March 4, 2007; A01

The government is on track to approve a new antibiotic to treat a pneumonia-like disease in cattle, despite warnings from health groups and a majority of the agency's own expert advisers that the decision will be dangerous for people.

...check this. (LATER: The link is actually there now...)

USDA Backs Production of Rice With Human Genes
By Rick Weiss
Washington Post Staff Writer
Friday, March 2, 2007; A02

The Agriculture Department has given a preliminary green light for the first commercial production of a food crop engineered to contain human genes, reigniting fears that biomedically potent substances in high-tech plants could escape and turn up in other foods.

The plan, confirmed yesterday by the California biotechnology company leading the effort, calls for large-scale cultivation in Kansas of rice that produces human immune system proteins in its seeds.

Despite the Bush administration’s efforts to promote “consumer directed” health care, many companies are recognizing the limits to shifting too much of the cost of medical care to employees. Experience, Professor Reinhardt said, is contradicting the theory that “patients will be more prudent shoppers for health care if they ache financially when they ache physically.” 

Anyone with any understand of humans knew that was bullshit.

This bit sounds good, but do you REALLY want your job to be your health care provider? What next...will you be ultimately get your food and clothes from them? This is WAY to sharecropper for my comfort...and it's no replacement for a proper single payer system.

To Save Later, Some Employers Offer Free Drugs Now
By MILT FREUDENHEIM

For years, employers have been pushing their workers to pay more for health care, raising premiums and out-of-pocket medical expenses in an effort to save money for the company and force workers to seek only the most necessary care.

Now some employers are reversing course, convinced that their pennywise approach does not always reduce long-term costs. In the most radical of various moves, a number of employers are now giving away drugs to help workers manage chronic conditions like diabetes, high blood pressure, asthma and depression.

Major employers like Marriott International, Pitney Bowes, the carpet maker Mohawk Industries and Maine’s state government have introduced free drug programs to avoid paying for more expensive treatments down the road.

Representative Charles B. Rangel, the New York Democrat who heads the House Ways and Means Committee, said Thursday: “...He still acts as if Republicans were in complete control and Democrats had lost the election.”

Nope. It's worse than that.

One measure of the political difficulty facing the president’s plan for Medicare and Medicaid is that he sought $20 billion less in savings from the two programs last year, when Republicans controlled Congress, and few of those proposals were adopted.

It's all posturing, so Republicans can claim Democrats block progress when the budget is so absurd that even discussing it seriously is an obstacle to progress. Better to throw out his budget and start from scratch.

Bush Seeks Big Medicare and Medicaid Saving
By ROBERT PEAR

WASHINGTON, Feb. 1 — President Bush will ask Congress in his budget next week to squeeze more than $70 billion of savings from Medicare and Medicaid over the next five years, administration officials and health care lobbyists said Thursday.

The proposals, part of a White House plan to balance the budget by 2012, set the stage for a battle with Congress over entitlement spending. Even some administration officials say they cannot imagine approval of such large cutbacks in a Congress now controlled by Democrats.

Mr. Spitzer has publicly blamed the union and hospitals t for out-of-control spending. Yesterday, he talked about institutions that,“through a combination of persuasive argument, political strength and effective presence here in Albany,” drive state spending.

Dennis Rivera, president of 1199, called that “an attack on each and every one of 600,000 health care workers in New York State.” He and Mr. Raske control a rich political action fund that can be used to finance attacks against politicians, but they have not yet threatened to go that route.

Mr. Rivera noted that the union and the industry recently accepted a state plan to close and merge a number of hospitals. “After doing that, to turn around and attack us as entrenched interest groups” is unfair, he said.

A Health Care Plan Both Ambitious and Contentious
By RICHARD PÉREZ-PEÑA