Personal Best - Repeat Injuries Don’t Stop Some Amateur Athletes

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Some States Are Lacking in Health Law Authority

Insurance commissioners in about half the states say they do not have clear authority to enforce consumer protection standards that take effect next month.

Federal and state officials are searching for ways to plug the gap. Otherwise, they say, the ability of consumers to secure the benefits of the new law could vary widely, depending on where they live.

Meanwhile, state governments that have for years allowed insurers to set premiums virtually at will are gearing up to establish procedures to review rate increases.

Under the new federal standards, insurers generally must offer coverage to children under 19 and must allow adult children up to age 26 to stay on their parents’ policies. Insurers cannot charge co-payments for preventive services or impose a lifetime limit on benefits; must allow consumers to appeal a denial of benefits; and cannot rescind coverage, except in cases of fraud or intentional misrepresentation.

States have the primary role in enforcing many of the new standards. If a state fails to enforce a standard, the federal government will step in to do so— as it did in several states after passage of ahealth insurancelaw in 1996.

The federal government recently surveyed states to assess their enforcement capabilities, and the results suggest a patchwork of protections.

California, Florida, Hawaii, Michigan, Nebraska, Oklahoma, Virginia and Wyoming, among other states, said they did not have authority to enforce federal law.

Some state regulators said they would ask state legislators to expand their authority by putting the federal standards into state law next year. Others said they would rely on their powers of persuasion, the good will of insurers or general state laws that ban unfair or deceptive trade practices.

By contrast, Maryland passed a bill in April that explicitly authorizes its insurance commissioner to enforce consumer protections in the new federal law. Similar bills were signed in June by Gov. Bev Perdue of North Carolina and in July by Gov.John Lynchof New Hampshire.

Kathleen Sebelius, the secretary of health and human services, said she realized that“some states may lack the full authority they might need or desire to fully enforce” the new market rules.

The administration said its general approach was to have“states take a lead role in providing consumer protections, with federal enforcement only as a fallback measure.”

Sara Rosenbaum, a professor of health law and policy atGeorge Washington University, said this was an awkward arrangement.“The new law creates detailed federal standards for insurance, but does not give consumers a right to sue if insurers don’t live up to their obligations,” Ms. Rosenbaum said.

Kim Holland, the Oklahoma insurance commissioner, said,“We will have to seek explicit authority from our State Legislature to make sure we can adequately enforce all the new provisions of federal law.”

Ken Ross, the Michigan insurance commissioner, said,“I fully expect insurers to comply,” even though his office“does not currently have clear authority to enforce the consumer protections enacted in federal law.”

Arizona said it was unlikely to pass legislation authorizing any state agency to enforce federal insurance standards, in view of its participation in a lawsuit challenging the federal law. Moreover, it said, Gov.Jan Brewerhas“instituted an indefinite rule-making moratorium, so we have no plans to adopt rules related to enforcement” of the law.

Some states hope to secure compliance by using their power to review insurance policy forms and contracts.

In a recent bulletin, the Texas Insurance Department encouraged insurers to file amendments to standard policy forms that would bring them into compliance with federal law. John Greeley, a spokesman for the department, emphasized the word“encouraged.”

“We don’t have authority right now to require it,” Mr. Greeley said.

Florida said that if insurers did not voluntarily revise their contracts, the state“has no legal authority to force them to do so.”

The Nebraska Insurance Department said it did not have“specific authority to order compliance with federal law in the face of a refusal to comply.”

Wyoming said it did not have the authority, under its insurance code or its Unfair Trade Practices Act, to enforce federal law even if it received consumer complaints.

New Jersey, New York and Ohio said they believed they had the power to enforce federal standards.

Gov.David A. Patersonof New York said his state would require insurers to rewrite their contracts to include the new consumer protections. State officials have developed model language. In addition, Mr. Paterson said, the Legislature will consider amending state insurance laws so they“meet or exceed” federal requirements.

Within days, the Obama administration is expected to announce up to $51 million in grants to states to help them perform one of their new duties: reviewing“unreasonable increases in premiums.”

Thirteen states currently have no authority to review proposed health premium increases for most forms of coverage, according to theNational Association of Insurance Commissioners. About a dozen have limited power to review increases after they take effect, while half the states require some form of state approval.

With insurers proposing heavy rate increases this year, possibly in anticipation of tougher regulation, several states have exerted their rate review authority with new vigor.

Sandy Praeger, the Kansas insurance commissioner and chairwoman of the health committee for the National Association of Insurance Commissioners, said states were eager to toughen their procedures to ward off federal interest in obtaining that authority.“The pressure is on us to prove that what we do is effective, and for states that don’t have the authority to get it done,” Ms. Praeger said. Many states will require legislation to change their rate review systems, she said.

States are also waiting for the federalDepartment of Health and Human Servicesto define unreasonable rate increases.

“That’s the big question,” Ms. Praeger said.“Unreasonable is a rather nebulous term.”

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Judge Revokes U.S.D.A. Approval of Modified Sugar Beets

The decision, by Judge Jeffrey S. White of Federal District Court in San Francisco, appears to effectively ban the planting of the genetically modified sugar beets, which make up about 95 percent of the crop, until the Agriculture Department prepares an environmental impact statement and approves the crop again, a process that might take a couple of years.

The decisioncould cause major problems for sugar beet farmers and sugar processors. In the past the sugar industry has warned there might not be enough non-engineered seeds available. However, the judge ruled that crops currently in the ground can be harvested and made into sugar, so the effects will not be felt until next spring’s planting season.

Beets supply about half the nation’s sugar, with the rest coming from sugar cane. Sugar beet growers sold the 2007-8 crop for about $1.335 billion, according to government data.

The decision came in a lawsuit organized by the Center forFood Safety, a Washington advocacy group that opposes biotech crops.

Judge White ruled last September that the Agriculture Department’s approval of the beets violated the National Environmental Policy Act, but he did not specify a remedy. Earlier this year, he denied a request by the plaintiffs to prohibit the planting of the engineered seeds this year, saying that would be too disruptive. But he warned farmers to move toward using conventional seeds.

In his order Friday, the judge granted the plaintiffs’ request to formally vacate the approval of the beets. That would bar farmers from growing them outside of a field trial.

But Judge White denied the plaintiffs’ request for a permanent injunction that would have also banned the growing of the crops. He said an injunction was not necessary if the crop was no longer approved for commercial planting. .

A decision by theUnited States Supreme Courtearlier this year in a similar case involving genetically engineered alfalfa essentially precluded the granting of an injunction.

In the alfalfa case, theSupreme Courtindicated that the government might grant partial approval of agenetically modified crop. It seems that such an option might be available in the sugar beet case as well, which could reduce any hardship for farmers. It is also possible the Agriculture Department will appeal.

Caleb Weaver, a spokesman for the Agriculture Department, said Friday night that the department was“looking at the decision to figure out what’s appropriate as the next step.”Monsantodeclined to comment, saying it would defer to sugar growers and processors.

Duane Grant, a sugar beet farmer in Rupert, Idaho and chairman of the Snake River Sugar Company, said he had not seen the decision and could not assess its impact.

But Mr. Grant, who had intervened in the case, added,“I’m pleased that the crop that is currently planted would be allowed to be harvested and processed. That’s clearly in the best interest of the public.”

Andrew Kimbrell, executive director of the Center for Food Safety, said the ruling was another sign the Agriculture Department was not doing its job.“This is regulation by litigation,” he said.

The ruling followed a hearing held earlier Friday in Judge White’s courtroom.

The Agriculture Department and its allies had argued that the approval of the crop should not be revoked, saying the department’s mistakes were not that serious and that the crop was going to be eventually approved anyway. At the least, they asked for a nine-month delay in revoking the approval to give the department time to put interim measures into place.

But Judge White disagreed, writing in his opinion that the Agriculture Department’s errors“are not minor or insignificant” and that it had already had time since his initial ruling in September to put interim measures into place.

The judge said it was not clear legally if he could consider the economic consequences of revoking the approval, but that even if he could, the Agriculture Department had not adequately demonstrated there would be a severe impact.

In his previous ruling, Judge White said the department had not adequately assessed the consequences from the likely spread of the genetically engineered trait to other sugar beets or to the related crops of Swiss chard and red table beets.

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Patient Money - Filling In the Insurance Gap for Adult Children

But not until January. In the meantime, she will renew the student policy she had last year, even though the coverage isn’t as good and the price, $1,745 for the year, is much steeper than rejoining her father’s plan, which she will be able to do free.

“It’s extremely frustrating,” she said.

Finding a health plan for college-age children isn’t something parents have had to think much about. Most decide to keep their children on their employer’s plan, which is typically more comprehensive than coverage offered through the school or in the market for individual policies.

But many health plans limit coverage of college-age children for a variety of reasons, including age, whether they live at home and whether they are financially dependent. For families with those plans, the choices are more difficult. And the health care law has addedwrinklesto an already complicated decision.

Under the new law, employers will be required to offer to cover adult offspring until they are 26, regardless of their student status or whether they are financially dependent on their parents. The provision takes effect on or after Sept. 23, whenever health plans renew coverage.

For many companies, that means January 2011, but for others it could be March or even July. So students like Ms. Zaidenweber face a gap in coverage of several months.

Because of a pre-existing condition, she does not qualify for an individual insurance policy to tide her over until January, when she will rejoin her father’s plan. But Georgetown won’t permit her to buy student coverage for just one semester, so beginning in January she will be doubly insured.

For many such students and their families, finding adequatehealth insuranceremains a challenge. Here are strategies to consider.

EMPLOYER PLANSEmployer plans generally offer more comprehensive coverage than student or individual policies. But don’t assume the company plan is the best choice.

If you haven’t done so, check with your human resources department to make sure your child will be covered in the fall. If there is going to be a gap, find out your health plan renewal date and when the enrollment period will be held to add adult children.

If your plan doesn’t renew until next year, under the federal Consolidated Omnibus Budget Reconciliation Act, Cobra, you can keep your child on your employer plan in the interim. But you will be responsible for paying the premium to cover the child.

Cost is another important question. Once the plan renews its policy, the new health care law prohibits employers from charging a higher rate for adult children who are newly eligible for coverage. Companies can charge more for all dependents, however, and many may do so.

In a recent survey by Mercer, a human resources consulting firm, one third of employers said they would strongly consider increasing the premiums for dependent coverage to offset the higher costs of covering adult offspring. If your company plans to do this, you may want to consider other options, such as individual insurance, especially if your child is healthy.

The new health care law eliminates some barriers for parents who want to keep college students on the family plan, but obstacles remain. One all-too-common difficulty: If your child is going to school out of state, your health plan may not cover most services there.

That’s the situation facing the Davis family of Malibu, Calif. Skyler Davis, 18, is heading to Drexel University this fall, but the family’s health maintenance organization will cover him only for emergency or urgent care, not routine doctor appointments, while he’s in Philadelphia.

So the Davises will probably buy Drexel’s student plan, at $1,140 a year. Elyse Davis concedes she does not like the $50,000 per condition per lifetime cap on benefits.

“You go into the hospital for two days, and that could do it,” she said.

STUDENT POLICIESA majority of colleges offer student health insurance, and some provide solid coverage— but they are the exception.“Most student plans are really bad,” said Stephen Beckley, a health care management consultant for colleges and universities in Fort Collins, Colo.

Student health plans must meet new standards under the health law, but the specific regulations have not been issued. The law is likely to have no effect this fall, since those health plans are already in place.

If you’re considering buying a college plan, look for several important elements, said Mr. Beckley and other experts. They include: catastrophic coverage of at least $1 million in lifetime benefits; no exclusions of coverage for pre-existing conditions if your child was covered immediately before signing up; first-dollarmental healthcoverage, not subject to a deductible; and solid prescription drug coverage.

As more parents see cuts to their generous employer health benefits or lose them entirely, some student health plans, even ones that aren’t particularly robust, are starting to look at least somewhat attractive.

Donna and Brent Funck’s daughter Brenna, 18, will attendTulane Universityin New Orleans this fall. Mr. Funck owns a software business, and the family is insured through an individual policy. Brenna Funck, however, has a congenital heart defect that makes her difficult to insure. The Funcks pay $300 a month for a separate individual policy for her, with a $2,500 deductible.

Tulane’s policy isn’t ideal for someone with a medical condition that may require expensive care. The policy maxes out at $250,000 per condition per lifetime.“One event that requires surgery would wipe that out,” Ms. Funck said.

But the $1,754 annual premium is a lot less than the Funcks pay, and the deductible is just $250. Despite reservations, they said they will sign her up.

INDIVIDUAL PLANSIf the parents’ insurance isn’t an option and the school policy is poor or nonexistent, students who are healthy may be able to get a good deal on an individual policy.

The average rate for an 18- to 24-year-old is $106 a month for a plan with a $2,300 deductible, said Carrie McLean, a consumer specialist witheHealthInsurance.com, which sells policies from 180 insurers through its Web site.

Individual policies are not known for being generous, but they may be a better choice for students than in years past. Under the health care law, new individual plans must meet new standards beginning Sept. 23, including no lifetime limits on coverage and free preventive care.

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Antibiotic-Resistant Bacteria Moving From South Asia to U.S.

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A Heart Pump Ticks Down, and a Stranger Steps In to Help

Mr. Volpe, 67, a slight, gray-haired man, looked in his car for the bag he always keeps nearby with spare batteries. But, no bag. In his mind’s eye he saw exactly where he had left it, to make sure he would not forget it, on a chair near the door back home— an hour and a half away. He thought of the clever little hand pump he had been given to keep his mechanical heart going in an emergency. It, too, was in the missing bag. Standing in the parking lot, he could hear one thing. Beep. Beep. Beep.

“I have to admit, I panic,” he said.

Mr. Volpe is one of thousands of Americans who have had these pumps, called left ventricular assist devices, surgically implanted to help their failing hearts. FormerVice President Dick Cheneyis another. Sometimes the pumps are used to keep people alive until a transplant becomes available, but in other cases they are meant to remain as long as the patient lives.

Mr. Volpe, a retired subway conductor who had had two heart attacks and two bypass operations, had an assist pump implanted in October 2009 by Dr. Yoshifumi Naka at NewYork-Presbyterian/Columbia hospital.

The pump is placed near the patient’s own heart. A power line emerges about waist level and connects to a controller, a mini-computer which 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. The pump Mr. Volpe had, a HeartMate XVE, made by Thoratec, could run for about four hours on two batteries. The pumps cost $70,000 to $80,000, usually covered by insurance.

That day in the parking lot in December, in Fishkill, in upstate New York, Mr. Volpe was too far from Columbia to get there in time. But his wife phoned its heart-pump clinic, andnurse practitionerstold her to call 911 for an ambulance to the nearest hospital.

Mr. Volpe knew that if the pump stopped, he was not likely to die immediately; his own heart, though weak, would probably keep him alive. But he was still in real danger, because clots would form in the mechanical heart if it quit, and cause a stroke if they escaped into his bloodstream.

Dr. Donna Mancini, Mr. Volpe’s cardiologist and director of theheart failureand transplant program at NewYork-Presbyterian/Columbia, said the hospital had not encountered a situation like this before.

“But with these devices getting more use, it may arise,” Dr. Mancini said.

Right now, Dr. Mancini said, Columbia has 45 patients with pumps who are waiting for transplants. Just a few years ago, there were only 10.

She said she did not know why, but this year fewer donor hearts have become available than in the past, leaving more patients dependent on the pumps. Usually, the hospital performs 80 to 100 transplants a year.

“This year we’re on a course that will probably yield around 60 transplants,” Dr. Mancini said, adding that there were about 150 patients on Columbia’s waiting list.

Nationwide, 3,138 people are waiting for heart transplants, according to the United Network for Organ Sharing. Last year, 2,211 received new hearts.

Thoratec said that in the past decade or so, a total of 6,000 XVE devices and 5,000 of a newer model, the HeartMate II (the one Mr. Cheney has) had been implanted.

An ambulance took Mr. Volpe to Vassar Brothers Medical Center in Poughkeepsie. But that hospital does not implant assist pumps, and had no batteries or hand pump. Doctors there, advised by Columbia, began dripping in a blood-thinning drug, heparin, to prevent clots.

Meanwhile, Khristine Orlanes, a nurse practitioner at Columbia, began trying to find another patient with an assist pump who was close enough to bring Mr. Volpe a set of batteries in time.

She called Robert Bump, 61, a building contractor who worked near Poughkeepsie. He had six spare batteries in a knapsack.

“I’m on my way,” Mr. Bump said.

An electrician offered to drive, and they tore off in his pickup truck. The electrician called a state trooper friend, told him the story and said,“We’re not stopping.”

A police car met them partway to Poughkeepsie and escorted them. They made the half-hour trip in about 20 minutes.

Mr. Bump strode into the emergency room and spotted Mr. Volpe on a gurney, surrounded by doctors, nurses and his frantic wife. The alarm was still beeping. A doctor, noticing Mr. Bump’s black-mesh vest and the controller, said,“Oh, he’s got one, too.”

Mr. Volpe, who had no idea what plans had been hatched on his behalf, said:“I see this big fellow walk in. I recognized the outfit right away.”

Mr. Bump snapped the batteries in place and said,“O.K., you’re good.”

There was a small round of applause in the emergency room. Mr. Volpe could not stop saying thank you.

His pump, due to run out in 15 minutes, had somehow lasted nearly an hour, but apparently had just minutes left when Mr. Bump arrived.

The two men had different pump models that happened to use the same batteries. If Mr. Bump had been using a newer version of the batteries for his model, they would not have been compatible with Mr. Volpe’s.

“Mr. Volpe’s stars were aligned that day,” Mr. Bump said.“There is some reason that gentleman needs to be here.”

On July 24, after nearly a year on his assist pump, Mr. Bump made it to the top of the waiting list and received a transplant at NewYork-Presbyterian/Columbia. At the hospital, his wife overheard the spouse of another transplant patient say that she, too, was from upstate.

Mr. Bump’s wife mentioned that her husband had helped another patient from the same area who needed batteries for an assist pump.

“That was my husband,” the other woman said.

By coincidence, Mr. Volpe had also just received a transplant.

Last week, the two were up and about, in good spirits. Both said they owed their lives to the assist pumps— but were thrilled to be free of them. Both were desperate for showers, after nearly a year of sponge baths. They would not miss the vests, either. On more than one occasion, Mr. Bump had had to reassure strangers that he was not wearing a bomb.

Leaving a sitting room at the hospital last Thursday, Mr. Bump rose first and offered Mr. Volpe a hand getting up.

“No thanks,” Mr. Volpe said softly, smiling.“You gave me enough help, Robert.”

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Q and A - Water Safety - Question

A.If the water was clean when it went into the containers, if the jugs were perfectly clean and sanitized to begin with, and if you are sure the containers were never opened, it will not have become unsafe to consume.

If you have doubts about any of these factors, the water can still be used if it is purified. The purification methods usually suggested are filtering followed by boiling or adding a few drops (about eight drops per two-liter bottle) of unscented liquid householdbleach.

Authorities like theRed Crossand theFederal Emergency Management Agencyrecommend keeping emergency water supplies on hand in case of a disaster: a gallon a day per household member, enough for at least three days. It should be either commercially bottled water or chlorinated tap water put into clean, food-grade, soft-drink-type plastic containers, not cardboard juice or milk containers.

The authorities also recommend renewing the supply every six months and keeping it away from heat and sunlight, which encourage the growth of any microbes that may be present. Boiled water can be aerated to make it more palatable by pouring water back and forth between two clean containers.C. CLAIBORNE RAY

Readers are invited to submit questions by mail to Question, Science Times, The New York Times, 620 8th Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com. Questions of general interest will be answered in this column, but requests for medical advice cannot be honored and unpublished letters cannot be answered individually.

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