Dining Experiences, All Illicit, That Extend Beyond the Palate

In an old converted warehouse in San Francisco’s Mission district recently, about 65 gourmands dined by candlelight atThe Wild Kitchen, an event presented by the groupforageSF.

One after another, courses arrived from the kitchen: fish soup, duck fat potatoes, fusilli con cinghiale (pastawith wild boar). With each bite and sigh of delight, the crowd eagerly participated in a crime— a scrumptious one, but illegal nonetheless.

Welcome to the world of underground dining: gourmet pop-up restaurants that operate outside the system of health department licenses and inspections. Food lovers have attended these clandestine feasts for years, but the general public’s growing appetite for adventurous eating has caused the popularity of these events to rise and could produce a new generation of culinary stars.

Unless they get busted first.

“They’re renegade restaurants,” said Alison Bing, food writer and San Francisco Lonely Planet guidebook author, who has tracked the phenomenon.“People are willing to pay for a unique experience.”

Being illicit is part of the excitement, with diners learning the secret locations only hours before service. There is also a heightened level of camaraderie, since attendees eat together at large tables.

“It has a lot to do with the communal dining experience,” said Anil Margsahayam, co-founder of another underground eatery, the Stag Dining Group, so named because all five owners (chefs, hunters, marketers, performers and conservationists) are unmarried and want diners to mingle.

The Wild Kitchen’s menu— $100 per person (B.Y.O.B.) on two packed consecutive nights— was inspired by a recent trip to France by Iso Rabins, 29, a chef and the scruffy, charismatic founder of forageSF. As the group’s name implies, the dishes contained ingredients— mushrooms, leafy greens and seaweed— that were gathered in the wild.

Mr. Rabins described foraging as“collecting food that won’t run away.” The exception was the wild boar, which was hunted, shot and skinned on private property near Paso Robles. (After many hours of cooking, it tasted like pulled pork.)

Mr. Rabins, whose first name, Iso, means“seashore” in Japanese—“My parents were hippies,” he said— is one of the more prominent faces of the underground dining scene. He has taped segments for two coming Travel Channel programs,“Bizarre Foods” and“The Wild Within,” where he prepared“roadkill raccoon.” (The raccoon was supplied by the TV show, he noted.) He has about 22,000 subscribers to his newsletter, which promotes the dinners and a monthly Underground Market.

Attracting some 2,500 fans, the market allows home cooks to sell their creations— from fresh baked fruit tarts to savory meat dishes— an idea that runs afoul of health codes. At the first market in December 2009, city health department inspectors arrived.

“I was terrified,” Mr. Rabins said.“They said,‘This is illegal.’ ” The contretemps was resolved by making the market a membership event where attendees sign a release acknowledging the risks.

The restaurants, however, are not as easily legalized, since the meals are not prepared in inspected, commercial kitchens, and because ingredients that are foraged are not subjected to government safety regulations.

“People are taking a risk. If we get complaints, we’ll investigate,” said Richard Lee, manager of restaurant inspectors for the San Francisco Department of Public Health. But Mr. Lee said he knew of no cases where diners had become ill at the events.

Ms. Bing, who has attended underground dinners, said she had mixed feelings about the lack of health department oversight. As a food journalist, she considers inspection scores essential when covering restaurants, and she raised possible concerns about fair wages and compliance with environmental laws.

“We are close to a zero-waste environment, a zero-landfill environment,” said Matthew Homyak, a co-founder of Stag Dining.

As far as employees are concerned, volunteers work the events for now, but there are ambitions to become a thriving legal business, perhaps even to obtain a catering license.

In the meantime, they say they are following the same food preparation rules of any clean restaurant.“We’re keeping ourselves safe,” said Jordan Grosser, one of two professionally trained chef-owners with Stag Dining.

Mr. Rabins did not attend culinary school. He has a film degree from Emerson College and had limited professional cooking experience before this venture. His passion for foraged food, like city snails to make escargot, seems more of a personal calling.

“It really changes the way you view the natural environment,” he said.

Scott James is an Emmy-winning television journalist and novelist who lives in San Francisco.
sjames@baycitizen.org

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Health Spending Rose in 2009, but at a Low Rate

Still, health care accounted for a larger share of a smaller economy— a record 17.6 percent of the total economic output in 2009, the report said. The economy contracted while health spending continued to grow.

The nation spent $2.5 trillion on health care in 2009, for an average of $8,086 a person, and therecessionhad a profound influence.

“Many consumers decreased their use of health care goods and services, partly because they had lost employer-based private health insurance coverage and partly because their household income had declined,” said Anne B. Martin, an economist and principal author of the report, issued by the office of the actuary at the Centers for Medicare and Medicaid Services.

In many cases, Ms. Martin said, people decided to“forgo health care services they could not afford.”

The number of visits to doctors’ offices apparently declined. Manyhospitalsreported fewer admissions, as patients put off medical procedures. Spending on dental services declined slightly. Many hospitals and other health care providers reduced their capital investments. Spending on doctors’ services in 2009 increased at the slowest pace since 1996, according to the new federal study, being published in the journal Health Affairs.

Partly offsetting the slowdown in private health spending was a rapid increase inMedicaidspending, driven by the addition of 3.5 million people to the rolls.

Medicaid, created in 1965 to provide health care for low-income people, is financed jointly by the federal government and the states. The economic stimulus program approved in February 2009 temporarily increased the federal share, to help states in dire fiscal straits cope with a growing need.

“Federal Medicaid spending increased 22 percent in 2009, the highest rate of growth since 1991,” Ms. Martin said, while“state spending decreased 9.8 percent, the largest decline in the program’s history.”

Federal officials emphasized that none of the data reflected the impact of the new health care law, whichPresident Obamasigned in March 2010.

Spending on health care by private insurance companies grew a modest 1.3 percent in 2009, as the number of people with private coverage declined by 3.2 percent, or 6.3 million people. At the same time, out-of-pocket spending by consumers rose just four-tenths of 1 percent, compared with an increase of 3.1 percent in 2008.

Despite the economy’s downturn, retail spending on prescription drugs“increased more rapidly in 2009 than in 2008, as a result of more rapid growth in the prices of drugs and in the number ofprescriptionsdispensed,” the report said.

Retail purchases of prescription drugs account for $1 of every $10 spent on health care, almost $250 billion of the $2.5 trillion total in 2009.

Medicaid spending accounted for 15 percent of all health spending and totaled $373.9 billion in 2009, the report said. Many of the new Medicaid recipients are relatively healthy children and adults of working age. The new health care law calls for a major additional expansion in Medicaid eligibility, starting in 2014.

The recession ran from December 2007 to June 2009. Even after it ended, the economy was sluggish, and unemployment continued to rise. So the growth of health spending outpaced the growth of the overall economy in 2009, federal officials said.

The share of the economy devoted to health care rose one percentage point in 2009, the largest one-year increase in a half-century of record-keeping.

Health spending, as tracked by the government, has grown at a slower rate every year since 2002, when it increased 9.5 percent. The slowdown was more pronounced in 2008 and 2009 because of the recession.

Out-of-pocket spending by consumers— which includes deductibles, co-payments and the purchase of goods and services not covered by insurance— accounted for 12 percent of all health spending and totaled almost $300 billion in 2009, the report said.

In addition, it said, health insurance premiums increased more slowly in 2009 than per-person spending on medical benefits under private health plans. Insurers spent more on prescription drugs and“more on benefits for existing enrollees,” it said.

Republicans pounced on the new numbers.“No one should take solace in the fact that health spending grew at a lower rate in 2009,” said SenatorOrrin G. Hatchof Utah, who is in line to be the senior Republican on the Finance Committee.

Mr. Hatch said the new health care law could lead to“crushing increases in health costs and premiums.”

By contrast, the chiefMedicareactuary, Richard S. Foster, has estimated that the new law will lead to an increase of only nine-tenths of 1 percent in national health spending over 10 years.

Uninsured people who gain coverage will use more health care, Mr. Foster said, but the law is also supposed to reduce the growth of Medicare payments to many health care providers.

Medicare spending reached $502 billion in 2009, meaning that the program, for older Americans and the disabled, accounts for $1 of every $5 spent on health care. Enrollment in the traditional fee-for-service Medicare program declined, as some beneficiaries chose to enroll in private Medicare Advantage plans, federal officials said.

Over all, Medicare spending rose 7.9 percent in 2009, the same rate as in 2008, while enrollment grew about 2 percent, the report said.

Medicare spending increased an average of 2.3 percent for each person in a private Medicare Advantage plan and 6.9 percent for each person in the traditional program.

The new health care law cuts Medicare payments to private plans. Many studies have found that Medicare spends more on people in such private plans than it would spend for the same beneficiaries in the original Medicare program.

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With New Heart Pump, Cheney Slowly Resumes Old Life

WASHINGTON— A few days before Christmas, former Vice PresidentDick Cheneyended a self-imposed sabbatical from partisan politics to headline a fund-raiser for Maria Cino, a party operative and Bush administration official who is running to replaceMichael Steeleas head of theRepublican National Committee.

The fund-raiser for Ms. Cino, held at the Alexandria, Va., home of Mr. Cheney’s former aideMary Matalin, was his first major foray into partisan Washington political theater since receiving a mechanical heart pump in July that has, most doctors say, saved Mr. Cheney’s life by taking on the task of helping to push blood through his arteries.

Mr. Cheney, as he did at several holiday receptions in Washington, chatted about his new pump. At one cocktail party, he even opened his coat jacket to show it off. While Mr. Cheney is noticeably thinner— his trademark stiff, one-sided grin now shows up on a markedly leaner face— he is returning, associates say, to his old life, including hunting and socializing.

But for the most part, Mr. Cheney, 69, has put aside his public role as the fiery, combative political figure of the last two years, who seemed to relish every opportunity to engage in verbal jousting withPresident Obama.

WithGeorge W. Bushhaving decided to stay largely silent during Mr. Obama’s tenure, Mr. Cheney embraced the role of public critic, accusing the new, young president of rolling back Bush-era policies and undermining the nation’s security. In 2009, Mr. Cheney and Mr. Obama gave dueling speeches on the same day.

Now, however, family members and friends paint a portrait of a man less focused on the day-to-day back-and-forth in Washington and one more interested in documenting his years of service in a memoir and navigating life with his new pump.

Mr. Cheney’s heart will never beat at full strength again, doctors say. His new mechanical pump, a partial artificial heart known as a ventricular assist device, leaves patients without a pulse because it pushes blood continuously instead of mimicking the heart’s own beat. Most pulse-less patients feel nothing unusual, but the devices do pose significant risks of infection. They are implanted as a last resort either for permanent use or as a bridge to transplant until a donor heart can be found. Mr. Cheney, who has participated in some of the nation’s toughest decisions for decades, now faces a crucial one of his own: whether to seek a full heart transplant.

It is a decision he will most likely be forced to make within months. He is old enough that soon he will no longer qualify for a transplant, doctors say. And while it is possible for some patients with Mr. Cheney’s device to live for years, the long-term prospects remain unknown.

His family and friends will not talk publicly with any specificity about the former vice president’s heart condition or the steps he might be taking to confront it.

But in the meantime, Mr. Cheney has begun resuming his old activities. Besides the Cino fund-raiser, he attended a round of holiday parties in Washington— leaving whispers in his trail about his weight loss.“For all of the caricatures of him, he never lets it get under his skin,” said Ms. Matalin, a close friend.

Mr. Cheney, who spent the holidays at his ranch in Wyoming, recently had a class ofWest Pointcadets over to his house in McLean, Va., to talk about his experiences working for four of the last five Republican presidents and what it was like to work at the White House. In Wyoming, he has been spotted in local grocery stores, stocking up to make chili and spaghetti sauce,“as well as walking me through how to cook Christmas dinner,” his daughterLiz Cheneysaid in an e-mail.

But most of all, Ms. Cheney said, her father has been working on his book, which is scheduled to come out this fall.“He still prefers to write in longhand on yellow legal pads despite my efforts to introduce a laptop into his process,” Ms. Cheney said.

By supplementing the amount of blood pumped through the body, Mr. Cheney’s pump allows him to do many things he would do with a working heart. Such patients can bicycle, golf, play tennis, drive, shop and generally do what they did before they developed severe heart failure. They need to take an anticoagulant, like warfarin (sold under the brand name Coumadin), and have blood tests to monitor the amount.

Mr. Cheney’s pump was placed near his heart. With most patients, a power line emerges about waist level and connects to a controller, a minicomputer that plugs into a pair of one-and-a-half-pound, 12-volt batteries. Patients wear a black mesh vest over their clothing that holds the controller and batteries.

Mr. Cheney’s friends and family say he is making plans to get out in 2011 and give more speeches. On Jan. 20, he is to fly to Texas for the 20th anniversary of the Persian Gulf war with the first President Bush, the emir of Kuwait and a host of alumni of that administration, includingBrent Scowcroft, the former national security adviser, andColin L. Powell, who was chairman of theJoint Chiefs of Staffat the time, when Mr. Cheney was defense secretary.

On Dec. 28, Mr. Cheney was the host of a fund-raiser at the home of some friends in Jackson, Wyo., for a scholarship program that he and his wife, Lynne, have begun at theUniversity of Wyoming. They donated $4.5 million to help create scholarships for students to study overseas. In his remarks, Mr. Cheney said that after getting kicked out of Yale twice, he owed getting his life back on track to the University of Wyoming.

Mr. Cheney’s heart pump is also allowing him to go to the movies.

“He and my mom went to see‘True Grit’ at the Teton Theater here in Jackson a few days ago,” Ms. Cheney said. Her parents, she said, gave it“two thumbs up.”

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Graphic H.I.V. Ad by New York City Splits Activists

To music that telegraphs calamity, the advertisement warns ofosteoporosis,“a disease that dissolves your bones,” flashes a gory picture of analcancerand delivers a punch line about the importance of usingcondoms.

TheNew York City Health and Mental Hygiene Departmentreleased the advertisement onYouTubeand television in early December, intending to show that even though an H.I.V. diagnosis is no longer a death sentence, neither do H.I.V. drugs guarantee good health. But since then, several mainstream gay groups have organized against it, calling it stigmatizing and sensationalistic, and demanding that the city pull it from circulation. And in response, other gay activists have rushed to the health department’s defense.

“It’s about time,”Larry Kramer, the writer and a founder of Act Up, wrote in an e-mail to friends and fellow activists after seeing the spot.“This ad is honest and true and scary, all of which it should be. H.I.V. is scary, and all attempts to curtail it via lily-livered nicey-nicey‘prevention’ tactics have failed.”

For New York, the H.I.V. advertisement is just the latest in a series of graphic YouTubepublic service adstackling health issues likesmoking,obesityand childhood poisoning, created to reach young people through a medium they understand.

The H.I.V. public service ad falls into a tradition of attention-grabbing messages going back to the high school driver’s education films of car crashes on rain-slicked highways, and the graphic films aboutsyphilisshown to Army recruits. A more recent model might be the“Truth” antismoking campaign, which tapped into young people’s suspicions of the adult world, sponsored by the American Legacy Foundation, as part of the 1998 tobacco settlement.

Health officials said the spot had also appeared on television and would continue to run through mid-January on TimeWarner, Cablevision and FiOS cable networks, WNYW (Channel 5) and WPIX (Channel 11).

Some gay organizations are not happy.

“We know from our longstanding H.I.V. prevention work that portraying gay and bisexual men as dispensing diseases is counterproductive,” said Marjorie Hill, chief executive ofGay Men’s Health Crisis.“Studies have shown that scare tactics are not effective.”

Jarrett Barrios, president of theGay and Lesbian Alliance Against Defamation, known as Glaad, said the advertisement“misses the mark in fairly and accurately representing what it’s like to live with H.I.V./AIDS.”

But city health officials say the advertisement was tested on focus groups of the target audience— primarily Latino and black men between ages 18 and 30— and also reflected the city’s experience of what worked in its past antismoking campaigns, which included stomach-turning images of amputated fingers, tracheotomies and what was depicted as a dead smoker’s aorta.

“One of the points they kept making is you need to hit hard and do something to counteract the pharmaceutical ads that say having H.I.V. is a walk in the park,” Dr. Monica Sweeney, assistant commissioner of the city’s bureau of H.I.V. prevention and control, said recently.

Dr. Sweeney said the city stood by the advertisement and was pleased that it was getting attention, even if through controversy.

The campaign, which cost $726,000, was produced by DCF Advertising and financed by a federal grant, officials said.

In the last few days, theNational Association of People with AIDSand theH.I.V. Health and Human Services Planning Council of New Yorkhave added their voices to the opposition. Another group,Housing Works, also opposes the spot, a spokesman said.

In a Dec. 17 letter to MayorMichael R. Bloomberg, the planning council, which includes service providers and people living with H.I.V./AIDS, said that while it was true that older adults with H.I.V. might be at greater risk of developing cancer,dementiaand osteoporosis, the ad“implies that young adults living with H.I.V. suffer from these conditions, too— and that is false.”

The letter said that getting more advice from gay men into how to promote H.I.V. prevention, and“acknowledging their resilience in the face of this epidemic, will be far more successful than perpetuating outdated images of sickness, dying and death.”

The advertisement’s critics cited research by Peter Salovey, apsychologyprofessor at Yale, and colleagues, who found that threatening messages did not necessarily lead people to adopting healthier behaviors and could be counterproductive. The researchers also found that many preventive health behaviors, like using sunscreen, could be better promoted through positive than negative messages. Ina 2002 paper, Dr. Salovey and his colleagues said,“One could hypothesize that condom use, because it is a preventive behavior, would be better promoted by stressing its benefits.”

But Dr. Salovey said he had also published research showing that negative-consequence ads did work better for some health campaigns, including one in which low-income minority women were urged to undergo H.I.V. testing.

He added that he could not pass judgment on New York’s condom advertisement.“As our research shows,” he said in an e-mail,“there are situations when messages stressing benefits are more persuasive and other situations when messages stressing the risks of not taking action are more persuasive.”

Dr. Howard Grossman, a Manhattan internist and H.I.V. specialist, said the city’s approach was worth trying.

“Younger gay men are not making some kind of rational choice to have unprotected sex the way many activists are maintaining in this disagreement,” Dr. Grossman said.“These younger people are, like most young people having sex, living in the moment and making split-second, uninformed choices about unprotected sex.

“The point is that there’s a whole new generation out there who needs to learn that H.I.V. is a disease to stay away from, and so a fear-based ad directed at them is a whole new thing.”

Mr. Kramer, the author of“The Normal Heart,” an autobiographical play about AIDS in 1980s New York City, said H.I.V. treatment had bred complacency and a false sense of safety to gay men too young to remember a generation of gay men dying.

“Everybody thinks all you need to take is one pill, which is just malarkey,” said Mr. Kramer, who is H.I.V.-positive.“Nobody takes one pill. I mean, I take like 10.”

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Gay or Straight, Teenagers Aren’t So Different

That risk is hard to measure, in part because so much research has focused on clinical populations— people who sought help or acted out because they were troubled, had attempted suicide or professed suicidal tendencies. That tends to skew the results, suggesting that gay teenagers on average are more prone to suicide and mental illness than they really are.

The good news is that recent research finds more similarities than differences among gay and straight adolescents. For example, studies in Salt Lake City by Lisa Diamond, an associate professor ofpsychologyand gender studies at theUniversity of Utah, found that young gays had as many friends and were just as popular and socially connected as other teenagers.

The composition of their friendships is somewhat different, she noted. Gay teenagers tend to go out of their way to befriend youths of other races or those who are stigmatized for their looks.

But for gay and straight teenagers alike, Dr. Diamond said in an interview, the chief source of stress is the same:“anxiety about being alone as an adult, about finding the kind of partner they want.”

Finding a Balance

Studies do suggestthat severe emotional distress is somewhat more common among gay teenagers than straight ones. But Dr. Diamond and other experts say the effects of bullying and discrimination are often overplayed in the news media.

“I’m concerned about the message being given to gay youth by adults who say they are destined to be depressed, abuse drugs or perhaps commit suicide,” Ritch C. Savin-Williams, a professor of developmental psychology who is director ofCornell’s Sex and Gender Lab, said at a recent news briefing.“I believe the message may create more suicides, moredepressionand moresubstance abuse. I worry about suicide contagion. About 10 to 15 percent are fragile gay kids, and they’re susceptible to messages of gay-youth suicide.”

In an interview, Dr. Savin-Williams said:“We hear only the negative aspects from research. We don’t hear about normal gay teens. It’s hard to get studies published when researchers don’t find differences. A large number of studies found no group differences between gay and straight youth, but these have not been published.”

In his book“The New Gay Teenager” (Harvard UniversityPress, 2005), Dr. Savin-Williams noted that it is much easier to get grants to study clinical problems and treatment; only recently have the lives of gay teenagers in the general nonclinical population begun to be studied by developmentalpsychologists.

These later studies find that straight youths are just as much at risk of being bullied if they exhibit atypical behavior, he said. Bullies react to nonconformity, and they pick up on people’s weaknesses.

“Bullying is less about sexuality than about gender nonconformity,” Dr. Savin-Williams said.“There are straight youth who are gender-atypical and they suffer as much as gay kids. But whether there’s a direct link between bullying and suicide among gay teens has not been shown.”

Rather, recent studies show that the risk factors for suicide are identical for gay and straight youth. These, Dr. Savin-Williams said, include“prior mental illness, depression,bipolar disorder, dysfunctional families, breakups in relationships, suicide in the family and access to means.”

Still, there are also clear signs of continued stress on gay teenagers.A national studyof more than 15,000 middle and high school students published last month in Pediatrics found that gay, lesbian and bisexual teenagers were more likely to be harshly punished by schools and courts than their straight peers.

‘Life Can Be Good Right Now’

“The negative message that gay teens get— just survive youradolescenceand life will get better— is a disservice,” Dr. Savin-Williams said.“The message should be that your life can be good right now.

“Many gay youth have excellent, productive, happy lives. When asked, gay youth can come up with a very long list of positive attributes— they’re more artistic, creative, resilient and sensitive to the needs of others. They say they don’t have to be the most popular.”

The Gay, Lesbian and Straight Education Network (www.glsen.org), a national organization established in 1990 to improve school safety for all students, is an important force in fostering acceptance and countering negative images, discrimination and bullying directed at gay teenagers. The network maintains a registry of Gay-Straight Alliances (www.gsanetwork.org), student clubs that, as of 2008, have been established in 4,000 schools around the country. The first such alliance was proposed by a straight student who wanted to curb bullying and harassment of fellow students who were gay.

Gay teenagers most at risk for serious emotional distress are those whose families have rejected them, Dr. Diamond said.“There’s nothing harmful about keeping their same-sex attraction a secret for a while” if they think their parents will respond badly, she went on.“Often parents are better able to deal with this information when the kids are older.”

Her advice to parents:“Continue to express affection for your kids despite your own feelings about homosexuality. Let them know they are loved and accepted. Hug them, spend time with them, watch movies together.”

Moreover, she continued, parents and teachers often mistake a youngster’s underlying intent in seeking a partner.“They want to find a boyfriend, someone to love,” she said of gay adolescent boys.“These are not sexual concerns, they’re relationship concerns— and they are just as common among heterosexual as homosexual youths. They are classic adolescent worries.

“Adults should take a deep breath and answer their questions, saying something like,‘I’m sure you’ll find someone who will love and appreciate you.’ ”

As for suicide, Dr. Diamond said:“What most commonly precipitatessuicide attemptsin both heterosexual and homosexual adolescents is being dumped by a romantic partner. Kids who lose someone they cared about need to be listened to in a sensitive way, offered support and comfort, and reassured that this is not their only chance of finding love.”

David M. Huebner, an assistant professor of clinical psychology at the University of Utah, has just produced an informational video,“Lead With Love,” that gives parents concrete examples of how to respond when their children come out to them. It can be viewed free atwww.leadwithlovefilm.com.

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Co-Pay Coupons for Patients, but Higher Bills for Insurers

The reason, it turned out, was that patients were using a card distributed by the maker of an expensive antibiotic used to treatacne, sharply reducing their insurance co-payments. With their out-of-pocket costs much lower, consumers had switched from generic alternatives to the more expensive drug.

With drug prices rising and many people out of work, pharmaceutical companies are increasingly helping patients with their co-payments. The use of such co-payment cards and coupons and other types of discounts has more than tripled since mid-2006, according to IMS Health, an information company that tracks the pharmaceutical industry.

Last month, for instance,Pfizerintroduced a new card that can reduce the co-pay on its blockbuster drugLipitorto $4 a month, a savings of up to $50. That brings the out-of-pocket cost in line with what consumers might pay atWal-Martfor a generic version of a competingcholesterol-lowering drug.

Drug companies say the plans help some patients afford medicines that they otherwise could not.

But health insurers and some consumer groups say that in many cases, the coupons are just marketing gimmicks that are leading to an overall increase in health care costs. That is because they circumvent the system of higher co-pays on costlier drugs that insurers use to encourage consumers to use less expensive products.

“The member is somewhat insulated from the cost of the prescription,” said Kevin Slavik, senior director of pharmacy at the Health Care Service Corporation, which runs Blue Cross and Blue Shield plans in Illinois and three other states.“In essence, it drives up the total cost of providing the prescription benefit.”

TheFood and Drug Administration, meanwhile, is studying the effect of the discounts on consumer perceptions, concerned that the coupons will make consumers believe that a drug is safer or better than it really is.

The acne drug that produced higher costs in 2008 for the Albany insurance company was Solodyn, a once-a-day formulation of an antibiotic called minocycline. A month’s supply of Solodyn sells for more than $700 ondrugstore.com, compared with about $40 a month for capsules of generic minocycline, which are generally taken twice a day.

Executives at Medicis, the company that sells Solodyn, have told investors that the co-payment card is used by an“overwhelming majority” of patients, and is largely responsible for doubling use of the drug, to 26,000prescriptionsa week.

Co-payment coupons and cards are distributed by drug company sales representatives to doctors, and are also often available directly to patients over the Internet. Patients present them at the drugstore when paying for their prescriptions.

Any shift to brand-name drugs can have a big impact on health care costs.

AtDistrict Council 37, a union representing public employees in New York City, 59 percent of claims for statins in the year ended in June 2009 were for brand-name products that cost the plan $17.3 million. The other 41 percent of claims were for generic statins, which cost only $179,000. A year ago, the health plan eliminated the co-pay on generic statins to encourage more use of them.

For very expensive drugs, co-pay assistance is almost de rigueur, because in some cases co-payments can be up to 20 percent of the price of the drug.Novartis’s new pill formultiple sclerosis, Gilenya, costs $48,000 a year, compared with $30,000 to $40,000 for rival drugs, which are injected. Novartis is offering to cover the entire co-pay, up to $800 a month, which is 20 percent of the drug’s monthly cost.

“It seems the best strategy for a pharmaceutical company is to price their drug as high as they possibly can and offer that co-pay assistance broadly” to insulate consumers, said Joshua Schimmer, biotechnology analyst at Leerink Swann, an investment bank.

Jazz Pharmaceuticalshas quadrupled the price of itsnarcolepsydrug Xyrem, to about $30,000 a year, over the last five years, according to a recent report from the securities firm Jefferies&Company. To cushion patients, the company recently increased its co-pay assistance to as much as $1,200 a month.

“We do want to avoid big jumps in price, abrupt changes in price, which can have a negative impact on payers, physicians and, most importantly, patients,” Robert M. Myers, Jazz’s president, told analysts in November, as the company increased Xyrem’s price by 22 percent. He added:“The coupon program, I will point out, does help patients get low monthly out-of-pocket costs, and this is a program that we are definitely committed to.”

Drug companies defend the coupons, saying they are helpful to consumers and allow patients and doctors to make decisions based on medical reasons, not costs. In many cases, such as with Lipitor and Solodyn, the rival drugs are not exact generics.

Jonah Shacknai, the chief executive of Medicis, said Solodyn’s once-a-day formulation reduces side effects and makes it easier for people to take their medicine. He also said many insurers paid far less for the drug than the price ondrugstore.com.

“No one is forcing anyone to prescribe Solodyn,” he said.“We think the public wins because we have facilitated access to a product that dermatologists are eager to prescribe.”

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Jon Stewart’s Advocacy Role in 9/11 Bill Passage

And does that make that comedian,Jon Stewart— despite all his protestations that what he does has nothing to do with journalism— the modern-day equivalent of Edward R. Murrow?

Certainly many supporters, including New York’s two senators, as well as MayorMichael R. Bloomberg, played critical roles in turning around what looked like a hopeless situation after afilibusterby Republican senators on Dec. 10 seemed to derail the bill.

But some of those who stand to benefit from the bill have no doubt about what— and who— turned the momentum around.

“I don’t even know if there was a deal, to be honest with you, before his show,” said Kenny Specht, the founder of the New York City Firefighter Brotherhood Foundation, who was interviewed by Mr. Stewart on Dec. 16.

That show was devoted to the bill and the comedian’s effort to right what he called“an outrageous abdication of our responsibility to those who were most heroic on 9/11.”

Mr. Specht said in an interview,“I’ll forever be indebted to Jon because of what he did.”

Mr. Bloomberg, a frequent guest on“The Daily Show,” also recognized Mr. Stewart’s role.

“Success always has a thousand fathers,” the mayor said in an e-mail.“But Jon shining such a big, bright spotlight on Washington’s potentially tragic failure to put aside differences and get this done for America was, without a doubt, one of the biggest factors that led to the final agreement.”

Though he might prefer a description like“advocacy satire,” what Mr. Stewart engaged in that night— and on earlier occasions when he campaigned openly for passage of the bill— usually goes by the name“advocacy journalism.”

There have been other instances when an advocate on a television show turned around public policy almost immediately by concerted focus on an issue— but not recently, and in much different circumstances.

“The two that come instantly to mind are Murrow and Cronkite,” said Robert J. Thompson, a professor of television atSyracuse University.

Edward R. Murrow turned public opinion against the excesses of Senator Joseph McCarthy in the 1950s. Mr. Thompson noted that Mr. Murrow had an even more direct effect when he reported on the case of Milo Radulovich, an Air Force lieutenant who was stripped of his commission after he was charged with associating with communists. Mr. Murrow’s broadcast resulted in Mr. Radulovich’s reinstatement.

Walter Cronkite’s editorial about the stalemate in the war in Vietnam after the Tet Offensive in 1968 convinced PresidentLyndon B. Johnsonthat he had lost public support and influenced his decision a month later to decline to run for re-election.

Though the scale of the impact of Mr. Stewart’s telecast on public policy may not measure up to the roles that Mr. Murrow and Mr. Cronkite played, Mr. Thompson said, the comparison is legitimate because the law almost surely would not have moved forward without him.“He so pithily articulated the argument that once it was made, it was really hard to do anything else,” Mr. Thompson said.

The Dec. 16 show focused on two targets. One was the Republicans who were blocking the bill; Mr. Stewart, in a clear effort to shame them for hypocrisy, accused them of belonging to“the party that turned 9/11 into a catchphrase.” The other was the broadcast networks (one of them beingCBS, the former home of Mr. Murrow and Mr. Cronkite), which, he charged, had not reported on the bill for more than two months.

“Though, to be fair,” Mr. Stewart said,“it’s not every day that Beatles songs come to iTunes.” (Each of the network newscasts had covered the story of the deal between the Beatles and Apple for their music catalog.) Each network subsequently covered the progress of the bill, sometimes citing Mr. Stewart by name. The White House press secretary, Robert Gibbs, credited Mr. Stewart with raising awareness of the Republican blockade.

Eric Ortner, a former ABC News senior producer who worked as a medic at the World Trade Center site on 9/11, expressed dismay that Mr. Stewart had been virtually alone in expressing outrage early on.

“In just nine months’ time, my skilled colleagues will be jockeying to outdo one another on 10th anniversary coverage” of the attacks, Mr. Ortner wrote in an e-mail.“It’s when the press was needed most, when sunlight truly could disinfect,” he said, that the news networks were not there.

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