Pill chill: Politics and weak demand keep RU-486 on the shelf

Columbia College Chicago

A 1999 New York Times article called it “the little white bombshell.”

Seattle doctor Suzanne Poppema said it was “the best means we’ve had yet for defusing the abortion conflict.”

And Columbia University ob-gyn Carolyn Westhoff predicted, “It will help get abortion back into the medical mainstream and out of this ghettoized place it’s been in.”

Eleanor Smeal of the Feminist Majority Foundation said that it would cause the number of abortion providers to “double overnight.”

They were all talking about the abortion pill, mifepristone — long known by its French name, RU-486 — which was supposed to revolutionize abortion in America by greatly increasing the number of physicians who would provide abortions and broadening the options available to women wanting to end a pregnancy.

But in the year since mifepristone was approved by the Food and Drug Administration and made available commercially as Mifeprex by Danco Laboratories, the reality has not lived up to the hype.

From the political to the medical

“People thought all these doctors were going to come out of the woodwork to offer the pill,” said Ron Fitzsimmons, executive director of the National Coalition of Abortion Providers in Alexandria, Va. “It hasn’t happened.”

While abortion clinics have been relatively quick to offer the “early option pill,” as Danco tags it, gynecologists and general practice physicians have lagged behind.

A tortuous FDA approval battle and restrictive labeling have made mifepristone expensive to offer to patients. Meanwhile, state laws put a burden on doctors seeking to provide medical abortions and open them up to harassment by anti-abortion activists.

A 1998 Henry J. Kaiser Family Foundation study reported that 45 percent of family practitioners polled said they would be “very” or “somewhat” interested in offering mifepristone once it was approved and available.

However, a new Kaiser survey released in September showed that only 6 percent of gynecologists and 1 percent of general practice physicians were offering the drug. An additional 16 percent of gynecologists and 7 percent of general practitioners said they were “likely” to begin offering the drug next year.

“Expectations were high,” Fitzsimmons said. “What happened was that for many years [mifepristone] was a political issue. So pro-choice activists were real excited about it. They had visions of this being something that would be almost a social revolution.

“That’s fine,” Fitzsimmons added, “but sometimes the political doesn’t connect with the reality of the clinics, necessarily. It was political, then it became medical.”

According to the Kaiser survey of 790 randomly sampled physicians, 40 percent of gynecologists and 37 percent of general practitioners said that they would not offer mifepristone because they personally opposed abortion.

But for those who were not personally opposed to abortion, the following were identified as “important” reasons they did not offer abortions:

  • 62 percent — lack of patient demand
  • 51 percent — concerns about protest or violence
  • 49 percent — lack of interest in performing abortions
  • 48 percent — office space not set up to offer medical abortions
  • 47 percent — too much political controversy surrounding abortion

Though mifepristone has been available in France since 1988 and according to the Population Council has been used safely by more than 620,000 European women, Fitzsimmons argues that American doctors are still becoming familiar with the drug.

“You want your physicians to be conservative,” he said. “You want them to take their time and read studies. You want them to feel totally comfortable. Slowly, but surely, the use is increasing.”

Fitzsimmons said that half of the 150 independent abortion clinics which belong to NCAP are offering the drug. Half of the National Abortion Federation’s members — about 200 healthcare facilities — are offering mifepristone.

And through September 2001, 5,000 women had medical abortions through Planned Parenthood clinics. There are about 1.2 million abortions in the United States annually, according to the Kaiser Foundation.

Nonprofit clinics like Planned Parenthood and clinics affiliated with the National Abortion Federation make up 65 percent of sales of Mifeprex, according to Danco, a private company which would not release exact sales figures.

Private practices and independent clinics together account for the other 35 percent of sales, said Pamela Long, a Danco media relations officer. Long said there was no breakdown of how much of that 35 percent was accounted for by clinics and how much by private physicians.

Not easy to offer

Fitzsimmons said that a lot of preparation goes into offering mifepristone. “It’s not just a pill that you can just start offering. You have to start setting up protocol and get staffing situations resolved.”

This is precisely what Chicago’s Planned Parenthood Near North Health Center, 1200 N. LaSalle St., has done.

“We have been preparing for approval for over a year,” explained Vasyl Markus, Planned Parenthood Chicago Area’s vice president for public policy.

The Near North Health Center took part in one of the many training sessions offered by the National Abortion Federation, which has trained more than 3,400 healthcare professionals in how to provide mifepristone counseling to women.

“Forty percent of women at our clinic choose the early option pill,” Markus said. “It’s very popular, and our staff is very well trained to answer women’s questions.”

Markus said he was not surprised that more physicians weren’t jumping on board. “For physicians, it’s too new and they don’t know how to incorporate it into their practices. It was pretty predictable, particularly in hindsight, that it would not be offered right away.”

Heather Boonstra, senior public policy associate at the Alan Guttmacher Institute in New York City, echoed this sentiment. “A big part of why mifepristone isn’t more available yet has to do with bureaucratic inertia on the part of abortion providers,” she said. “They have to set up a different system for medical abortion.”

Boonstra also said that lack of demand for the early option pill accounted for its limited availability. Indeed, it was the reason most offered by doctors for not offering the pill.

“It seems a lot of women don’t know that it’s been available, and they need to know that so they can request it,” said Christina Horzepa, a public information specialist with the Population Council. “And even among doctors, they’re not aware of it.”

This lack of demand comes in spite of a six-month, $2 million National Abortion Federation advertising campaign in magazines popular among women.

The group’s executive director, Vicki Saporta, claimed that 70 percent of women between 18 and 49 were exposed to the ads, which ran in magazines like People, Glamour, Self, Fitness and Essence.

In the months following the ad campaign, the group’s hotline volume increased from 2,000 to 4,000 calls, and 40 percent of callers were inquiring about medical abortion.

Meanwhile, Danco has targeted thousands of healthcare providers in a huge direct-mail campaign to let them know about Mifeprex and how to provide it.

While Danco would not release information about how much was spent on the direct-mail campaign and other efforts such as medical conferences and advertising in medical journals, a September 2000 Wall Street Journal story year sheds some light on things.

Journal reporter Rachel Zimmerman obtained two internal Danco documents which showed that the firm had raised about $34.7 million — including $23.4 million from its nonprofit partner, the Population Council — through March 2000.

This included a $10 million loan from the David and Lucille Packard Foundation and a grant from the Buffett Foundation. In addition, the company hoped to raise $2 million to operate through the first quarter of fiscal year 2001.

‘Early option’ arrives late in U.S.

In spite of all this investment by Danco and abortion-rights supporters, mifepristone has not yet had the impact many thought it would have. First, let’s retrace why abortion-rights supporters struggled for so long to get mifepristone approved.

Though the Supreme Court’s 1973 decision in Roe v. Wade gave American women a constitutional right to choose to end a pregnancy, exercising that right has never been easy.

The number of surgical abortion providers has been steadily declining due to harassment from anti-abortionists, less emphasis on teaching abortion in medical schools, and state laws which make providing abortions a costly and dangerous endeavor by requiring that abortion providers give certain information about their practices to the government and comply with regulations no other doctors must deal with.

In Illinois, for example, 90 percent of counties have no abortion provider, and between 1992 and 1996, the number of providers fell from 47 to 38, a 19 percent loss.

A July 11, 1999 New York Times article reported that 59 percent of abortion doctors are at least 65 years old. Most abortion doctors are trained in obstetrics and gynecology, and the percentage of ob-gyns willing to perform dropped from 42 percent in 1983 to 33 percent in 1995.

Furthermore, fewer and fewer hospital residency programs are teaching surgical abortions. For these reasons, nine out of 10 abortions are performed not in private physician’s offices but in clinics.

And the cost and inconvenience of operating clinics is foreboding. They remain a flashpoint in the ongoing debate over the speech rights of anti-abortionists outside and their isolation from the mainstream medical community increases costs and discourages new doctors from entering the field.

Mifepristone, which was first synthesized by researchers at the French pharmaceutical firm Roussel Uclaf in 1980, works by blocking progesterone, a naturally produced hormone that prepares the lining of the uterus for a fertilized egg and helps maintain pregnancy.

Without progesterone, the lining of the uterus softens, breaks down and bleeding begins. This usually occurs about two days after the drug is taken, and it is followed by another drug, misoprostol, which causes the uterus to contract, completing the abortion process.

Mifeprex is called the early option pill because unlike surgical abortion, it can be used earlier in the pregnancy. It can be taken anytime up to seven weeks, and of course the procedure is non-invasive.

“I just think having another option, especially one that’s earlier, is better,” said Heather O’Neill, director of public affairs at Danco. “Earlier tends to be safer.”

Women who have had medical abortions rate their experiences more favorably than women who have had surgical abortions, according to a recent study which appeared in the June 2000 issue of American Journal of Obstetrics and Gynecology.

Women who had medical abortions reported less anxiety during the process, which can be completed at home. And while only 58 percent of women having surgical abortions said they would choose the method again, 91 percent of women who chose medical abortions said they would choose the same procedure.

By 1988, mifepristone was available in France, but testing and even importation of the drug into the United States was banned.

Sweden and the United Kingdom approved mifepristone for use in the early ’90s, and in 1992 the New England Journal of Medicine concluded that mifepristone was a safe and effective contraceptive. Yet approval was still eight years away.

Only after President Bill Clinton was elected did FDA testing begin in earnest. After a series of attempts by anti-abortion activists to severely limit the availability of mifepristone, the FDA finally approved the drug on Sept. 28, 2000. Danco began shipping Mifeprex to providers in late November.

FDA places limits on availability

But abortion-rights supporters didn’t get everything they wanted from the FDA. First, the FDA required that a doctor, or someone directly supervised by a doctor, administer the drug.

“The FDA basically says that you need to assess gestational age, diagnose ektopic pregnancy and have backup in case the mifepristone doesn’t work,” NAF’s Saporta said. “We felt that advance practice clinicians — nurse’s assistants, physician’s assistants, nurse-midwives — could do that.”

Planned Parenthood Chicago’s Markus said that this would not prevent a nurse from administering the drug, but the nurse would have to be in the same office as a physician. So, for example, the Near North Health Center is the only office in Chicago capable of providing such service, and so it is the only Planned Parenthood clinic which offers mifepristone.

“Nurses already do ultrasounds,” Markus said. “That requires more skill than counseling someone about mifepristone.”

Also, three doctor’s visits are required: the first to be counseled and take the mifepristone, the second to come back two days later to take the misoprostol, and a third visit 14 days later to make sure that the pregnancy has been terminated.

“According to the literature I’ve read, it’s not medically necessary for the woman to come back in for the second treatment,” claimed Bonnie Scott Jones, staff attorney at the Center for Reproductive Law and Policy in New York City.

“She can just take [the misoprostol] with her. There’s no need for her to come into the doctor’s office for that.”

Safety or sabotage?

Others see the requirements as part of an attempt by anti-abortionists to make medical abortions more expensive to provide.

“All of that is just a deliberate attempt to drive up the cost,” said Glen Whitman, an associate professor of economics at California State University, Northridge.

“It’s a deliberate attempt to drive up the cost. So much of it is transparently unnecessary. Other equivalent procedures don’t require that level of involvement. It’s apparent that there’s no reason for these restrictions on this treatment, except to make it more difficult to access.”

Cost should definitely not be overlooked as an explanatory factor in mifepristone’s disappointing popularity thus far. More than half of women seeking abortions are under the age of 24, and mifepristone costs about $75 to $100 more than surgical abortions, which usually cost $325 to $350, according to the Guttmacher Institute.

While many clinics are charging the same for surgical and medical abortions so as to give women as much choice as possible, users of the abortion pill still bear the higher cost.

“The medication cost alone is so high, and when you add the physician fee and the cost of ultrasound, the price is prohibitive,” one Bergen County, N.J., abortion provider told the Bergen Record on Sept. 25, 2001. “Once we presented it to our patients, they all said. ‘No.’ ”

Also, many young or low-income women do not have schedules flexible enough to allow them not one but three visits to oftentimes inconvenient clinic locations, pointed out Toni Bond, executive director of the Chicago Abortion Fund. CAF has not yet funded any medical abortions for its clients because of the cost, Bond said.

“We simply cannot afford RU-486,” Bond said. “The clinic we work with charges $500, which is more than a surgical abortion. And this requires more than one visit, which means taking off of work, making arrangements to get childcare, getting to the clinic and so on.”

Danco’s Long and O’Neill both said that Mifeprex’s cost was “within range” of surgical abortions. It was designed to be “affordable to women while helping us recoup the cost of bringing the drug to market,” O’Neill said.

And there is the culprit, said economist Whitman. “RU-486 is an extreme example of what happens all the time,” he said. “The protracted FDA approval process substantially increases the cost of going through the research and development process.

“When firms are deciding what kind of R&D projects to go into, they have to pick the very best bets. Only if it promises great profits is it worth the cost of the approval process.”

Strengthen choice by reforming FDA

FDA reforms allowing for more free choice for patients to risk possible side effects of drugs in order to get experimental treatments or, in the case of RU-486, end a pregnancy without invasive surgery, would be an improvement, according to Dale Gieringer, California coordinator for the National Organization for the Reform of Marijuana Laws. Gieringer has written extensively about FDA investigational regulation of pain medications.

The high price of mifepristone is “caused by the FDA regulatory system where you have a government agency that dictates what is safe and effective for everybody,” Gieringer said.

“Unfortunately, these are subjective concepts. Most people choose what is ‘safe’ and ‘effective’ according to their own values. The normal way a free society deals with this is to place these decisions in a market context.

“Instead, today you have bureaucrats making these choices on their own political grounds. They are influenced and pressured by all these different special-interest groups, as happened in the case of RU-486, and it all becomes this big political football based on someone’s religious superstitions.”

Keep your laws off my doctor

Finally, there are intense hurdles at the state level which make becoming an abortion provider a tremendous sacrifice for any gynecologist or general practitioner, according to CRLP attorney Bonnie Scott Jones.

“Let me put it this way: It’s much more difficult to be an abortion provider than to be in regular practice,” Scott Jones said. In regular practice, as long as a doctor has a license and performs a quality standard of care, he or she will be left alone by the government.

“But if you’re an abortion provider,” Scott Jones said, “you’re probably going to have to register with the state.” Providers may have to perform tests that aren’t required. For example, South Carolina requires that a Gonorrhea test be performed before the abortion procedure is done.

Regulations determining the width of doors, the flow of air and other trivia may now apply to an abortion provider — regulations which do not apply to other doctors, Scott Jones said.

An especially harmful requirement is that a registered nurse be hired on at a first trimester abortion facility. This is because RNs are in high demand and often will opt to work at hospitals where pay and benefits are better.

“The purported intent of these laws is to protect the health of abortion patients,” Scott Jones said, “but the true intent is to achieve the [anti-abortionists’] goal of making abortion legal but impossible to get, by making it difficult to be an abortion provider and making abortion so expensive that it will be out of reach.”

Scott Jones said that all laws which apply to surgical abortion providers would also apply to medical abortion providers. So even if a gynecologist only wanted to offer medical abortion to current clients, he or she would still have to register with the state and comply with all applicable laws and regulations.

The most ominous of these, Scott Jones argued, were those requiring abortion providers to give the government information about themselves and their employees. This information is often obtainable through Freedom of Information Act requests.

“And it’s not like nobody cares,” Scott Jones said. “The information is routinely requested by anti-choice activists so they can harass abortion providers.”

A difference, but only in kind

Ultimately, the legal infrastructure is hostile toward abortion providers, Scott Jones said, and a different type of abortion is not going to make much of a dent in that.

“There was the implication that a lot of doctors were going to start offering the pill,” NCAP’s Fitzsimmons said of the hopes abortion-rights supporters had for mifepristone. “In many ways, that minimizes what this is about.

“We’re not just dealing with possible terrorism. This is more than just a procedure or a pill. If a doctor starts thinking about it, he has to consider whether he wants to expose himself to anti-abortion activists … Is it really worth it?”

Studies reveal mixed news on Hispanic digital divide

Hispanic Business Journal of Illinois

There is good and bad news when it comes to Hispanic computer ownership and Internet access, a 1999 U.S. Commerce Department survey reports.

While Hispanic computer ownership doubled between 1994 and 1998, Hispanic households were still half as likely to own a computer as were white households and 2.5 times less likely to have access to the Internet.

The 1999 study, “Falling Through the Net: Defining the Digital Divide,” showed that, even when controlled for income, both Hispanic computer ownership and Internet access from home lagged behind that for both whites and Asians. The ownership and access figures for Hispanics, however, were slightly better than those for blacks.

Some observers have criticized the study for being presented as new data when it is, in fact, two years old. With computer prices approaching the cost of a television or VCR and free Internet services operating nationwide, they say, the so-called “digital divide” has shrunk remarkably in the time since the Commerce Department survey was conducted.

Adam Clayton Powell III of the Freedom Forum has pointed out what he sees as a flaw in the Commerce Department survey — it did not measure Internet access outside the home. Powell points to a 1999 study by the Pew Research Center for the People and the Press, which showed that 62 percent of employed Americans go online through their jobs, and 75 percent of students go online from their schools, percentages far greater than at-home statistics for all people regardless of race or income.

Therefore, Powell concludes, once computer and Internet access outside the home is taken into account, the gap is virtually nonexistent.

However, other experts believe that most meaningful Internet experiences can only take place in the home. As Katie Hafner reported in The New York Times: “Experts say that the only way to fully appreciate the Web is to experience it and that the most useful experience, unfettered by the constraints of an institutional setting, comes with using the Internet from home.”

Another survey released in March and conducted by National Public Radio, the Kaiser Family Foundation and Harvard University’s Kennedy School of Government showed that at higher income levels the racial gap in computer ownership and Internet access virtually disappears.

The NPR survey also showed that while a gap in computer ownership and Internet access existed between whites and minorities at the lowest income levels, there was no gap in similarly-priced home electronics, like TVs, VCRs, and home stereos.

Contention over the existence and extent of the digital divide aside, there is little debate about the role computer ownership and Internet access will play in the future for all Americans, including Hispanics.

This is why some organizations are taking a proactive approach in ensuring that all people — especially children — have access to the computer technologies that will shape our future. For example, AT&T has offered a summer cyber-camp of sorts, free of charge, to selected Chicago-area children.

This year’s Cyber Navigators Camp will give some 35 ten- to 12-year-old children the opportunity to participate in a program exposing them to advanced computer technology, hands-on science activities, field trips and special speakers.

Designed for youths who do not have adequate access to computer technology, “The cyber skills these students acquire will be an important stepping stone to their overall success in school and as lifelong learners,” said Agnes Hicks, AT&T community relations manager.

The camp opened in June at El Valor’s Computer Technology Center, 1924 W. 21st St., in Chicago. Children were recruited from families already being served by El Valor and from other community-based organizations, churches and schools. The students who were selected had to write a 200-word essay in English or Spanish about themselves and their community.

“The application process was necessary because we knew the response to this program would be tremendous,” said Rolando Madrid, El Valor coordinator of school age programs. “The [camp] helps fill a great need in our community to engage youth who might not otherwise have the opportunity to learn about technology in such a hands-on environment.”

In addition to learning about computers and the Internet, the children will also learn how to interpret science data and work together to complete a science project. Field trips to the Chicago Academy of Sciences, the Shedd Aquarium and Telemundo TV will keep the kids from getting cabin fever.

While the camp only runs for six weeks, the children will have access to El Valor’s computer learning center even after the program ends.

With computer prices inching ever lower and lower and these types of efforts to increase computer and Internet access on the rise, perhaps the digital divide among Hispanics — whatever its breadth — will soon fade into memory.

To read the Commerce Department report in full or find out more about the digital divide, visit www.digitaldivide.gov.

Mental-health parity: simple fairness, or recipe for disaster?

Columbia College Chicago

Psychiatrists and advocates for the mentally ill call it a blow against unfair discrimination. Insurers and economists call it a sure-fire way to raise costs, erode other benefits, and throw millions off the insurance rolls. It’s mental-health parity.

For years, employers have cut insurance costs by scaling back mental-health benefits. While 95 percent of all employers do offer mental-health coverage, the amount they spend on physical coverage has routinely outpaced that spent on mental-health coverage by 20 to one. Whether this is the result of stigma or consumer demand is one of the questions at issue.

In the last decade, 19 states have passed some sort of mental- health parity legislation, and in 1996 Congress joined the fray by requiring that employers provide equal lifetime and annual benefits (in dollars) for mental illnesses as for any other medical or surgical benefits.

In an effort to keep down costs while obeying the letter of the law, employers have imposed limits on the number of inpatient and outpatient visits covered rather than the dollar amounts. Now two bills in Congress seek to close this so-called loophole.

Senate bill 796 (also known as “The Mental Health Equitable Treatment Act of 1999”), co-sponsored by Sens. Pete Domenici (R-N.M.) and Paul Wellstone (D-Minn.), would require employers to cover mental health exactly as they cover physical health, prohibiting limits on the number of visits. Both Domenici and Wellstone have relatives struggling with mental illnesses.

“Medical science is in an era where we can accurately diagnose mental illnesses and treat those afflicted so they can be productive,” Domenici said when he introduced the bill on April 14. “I would ask then, why with this evidence would we not cover these individuals and treat their illnesses like any other disease?”

Rep. Marge Roukema (R-N.J.) introduced her own mental-health parity bill in the House a week later. House Resolution 1515 (also known as “The Mental Health and Substance Abuse Parity Amendments of 1999”), treads the same ground as the Domenici-Wellstone bill, but also covers substance abuse and chemical dependency.

While both bills are stuck in committee, the issue has not faded from the spotlight. On June 7, Tipper Gore, mental-health advisor to the president (and the vice president’s wife) chaired the White House Conference on Mental Health, which addressed strategies to reduce stigma and featured President Clinton’s announcement of full mental-health parity for federal workers.

Gore, who suffered a serious bout of depression after her six-year-old son was seriously hurt in a car accident, was joined at the conference by “60 Minutes” co-editor, Mike Wallace. Wallace was diagnosed for depression several years ago and openly and jubilantly speaks about his success with the anti-depressant drug Zoloft.

While people like Wallace and Gore have the resources and the public acceptance to live comfortably with their illnesses, supporters of parity legislation say, that may not be true for the approximately 55.5 million Americans — nearly 25 percent of the adult U.S. population — who, according to National Institute for Mental Health statistics, suffer from some form of mental illness during their lifetimes.

“The reason why I think we need legislation is because the stigma exists, and because people are being discriminated against,” says Jennifer Heffron, director of public policy for the National Mental Health Association, the nation’s oldest advocacy group for the mentally ill, founded in 1908.

“The important thing,” says Heffron, “is that you don’t want to leave open a way for companies to discriminate.”

“It’s an issue of fairness,” says Jeremy Lazarus, chair for the American Psychiatric Association‘s joint commission on governmental relations. “There’s no reason that people who have mental illnesses should be stigmatized and not allowed to get treatment.

“It would be as if someone had diabetes or hypertension and they were told it was too expensive and they couldn’t get the treatment. Our view is that mental illness and substance abuse should be in the same fair pool of allocated money.”

But is the disparity between mental and physical coverage discrimination or consumer demand? Gail A. Jensen, joint professor of economics and gerontology at Wayne State University, says that mental-health coverage “is available, if workers and their employers wanted that kind of coverage, but they don’t because it’s not worth the premium.”

The legislation, Jensen says, “would amount to forcing on to insured people something that they don’t want to pay for. Mental-health care costs five to 10 percent of the premiums. An expansion of coverage could end up being quite costly.”

The question of how much parity legislation would raise costs is a matter of intense statistical debate. Michael Tanner, director of health and welfare studies at the Cato Institute, a libertarian think-tank in Washington, D.C. wrote in 1996 that mental-health parity “could raise insurance premiums by an additional 8 to 15 percent.”

Meanwhile, the National Mental Health Association reports a study showing an average of a mere one to four percent growth in premiums in states that have some form of parity legislation.

Tanner also argues that mental-health parity will actually encourage more people who otherwise would not need mental-health treatment to seek it out. Called induced demand, “it’s a fairly well-recognized phenomenon,” Tanner says, that once a benefit is mandated, people take much more advantage of it.

He cites the “famous” case of Hawaii, where chiropractors persuaded the legislature to mandate coverage. “The result,” Tanner says, “was a four-fold increase in chiropractors and skyrocketing costs.”

Tanner cited one observer who said, “If your employer is willing to pay for 30 visits to a psychiatrist, your psychiatrist will treat you in 30 visits; if your employer will pay for 60, it will take 60 to cure you.”

Heffron, for one, doesn’t see that happening. “Parity is delivered in the context of managed care,” she explains. “With the managed care system you have a gatekeeper. So just because there are available benefits does not mean you’re automatically going to get to them.

“There will be different mechanisms in place to determine whether you need the benefits. Managed care is one of the things that makes mental-health parity possible.”

Regardless, health insurance providers still oppose mental-health parity legislation. “We oppose all mandated benefit requirements,” says Richard Coorsh flatly. He is the assistant vice president for communications with the Health Insurance Association of America, which represents 269 health insurance companies.

“No matter how well-intended the benefit requirement may be,” Coorsh says, “mandates drive up the cost of health insurance and, as a result, make it more difficult for people to buy health insurance. Which, in turn, raises the number of uninsured Americans.”

But shouldn’t the mentally ill, stigmatized as they are, get the same treatment as those with physical illnesses? This contention “overlooks one key issue,” says Coorsh, “which is that because of the cost of coverage there are 43 million Americans who currently don’t even have the luxury of clamoring for an additional benefit because they have no insurance whatsoever.

“This, and other mandated benefit proposals, would only raise the cost of coverage and make insurance more out of reach.”

Michael Tanner puts it this way: “If you have to offer the Cadillac and were thinking of offering the Pinto, then you won’t offer anything.”

Gail A. Jensen confirms that 20 to 25 percent of those who are uninsured, about 10 million people, owe their situation to state and federal mandates on private health care.

“No mandate does any good,” Coorsh adds, “if people don’t have any insurance at all.”

Jeremy Lazarus, who has his own private practice, says that this argument misses the point. “It depends on what part of the elephant you’re looking at,” he says. “There is a substantial societal and health-care cost in terms of those who don’t get treatment. It shows up on some ledger book somewhere else. The prison system, the state hospital, emergency rooms, lost work time.

“No employer wants to see their costs go up if they cannot be assured that cost savings are going to accrue to their bottom line in a short period of time,” Lazarus says, explaining why he believes legislation is necessary.

“It might accrue to the bottom line of society, it might accrue to the benefit of some insurance plan, it might accrue to the bottom line of the state prison and jail system, but they’re not sure it’s going to accrue to their bottom line.

“No one’s going to step up to the plate first and raise their costs and their premiums if no one else is doing it,” Lazarus says. “You have to level the playing field by federal legislation.”

The National Institute of Mental Health agrees, estimating the annual cost of “untreated mental illnesses” at more than $300 billion due to “productivity losses, health care costs” and “increased use of the criminal justice system and social welfare benefits.”

Tanner says he’s heard it before. “That’s an unprovable argument that’s always made,” he says. “We’re told that we’ll save money, but costs always rise. We’re saving money right into the poorhouse.

“There are some cases where you might save money due to an early intervention, but with mandates, you’ll no longer have price competition and induced demand is only something that will show up in the long run.”

Lastly, some say that mental illness really is different from physical illness. Diagnosing “post-traumatic stress disorder” is not the same as fixing a broken arm, they say.

“Going beyond chemical brain diseases,” Tanner says, “which are rather easily diagnosed and cured, there are a lot of broad concepts like ‘anxiety.’ How do you determine something like that?”

Heffron disagrees, pointing out that “the success rate for treating clinical depression is over 80 percent, versus the 40 percent success rate for balloon angioplasty, a treatment for heart disease.”

The National Institute of Mental Health’s statistics show a 60 percent success rate in treating schizophrenia, a 70-80 percent rate for depression, and a 70-90 percent rate for panic disorder.

A parity bill is also winding its way through the Illinois legislature. Heffron reports that H.B. 111 “passed the House with flying colors, but was stalled in Senate Rules Committee.”

The bill would prohibit insurance providers from imposing durational limits, amount limits, deductibles and co-insurance for a number of severe mental illnesses.

Kosovo bombings spur anti-war activism online

Columbia College Chicago

As the conflict in Kosovo wears on, activists from across the political spectrum are utilizing the power of the Internet to express and organize their opposition to the U.S.-led NATO bombings, as well as their hope for peace in the Balkans.

Eric Garris is one such activist. He is the webmaster at Antiwar.com, which he calls a “one-stop shopping place for anti-war views and actions set in a broad-based, nonsectarian fashion.” Though four years old, Antiwar.com has “taken off” since NATO began bombing Kosovo, skyrocketing from 1,000 visitors a day to 55,000 a week, aided greatly by what Garris, 45, calls “word of Web.”

Run by the self-described “libertarian slash conservative” Committee Against U.S. Intervention, Antiwar.com features news-wire stories from around the world and essays from sources as disparate as conservative pundit Pat Buchanan and liberal weekly The Nation. “You can’t get this type of [anti-war] information in the American press,” says Garris, who avoided the Vietnam draft by simply not registering when he turned 18 in 1972.

Garris, a Web production manager for NurseWeek magazine in Sunnyvale, Calif., says the Internet “is a great equalizer. It allows people to do endless things with a small amount of money. The Internet gives everybody the ability to be a publisher,” as evidenced by Antiwar.com’s monthly budget of less than a $1,000.

While Antiwar.com attempts to provide a central location for Web users to get their anti-war information and opinion, StopTheWarNow.com, run by the Libertarian Party, tries to make petitioning Congress as easy as possible. Online since April, the Web site automatically submits each user’s petition form to his district representative and both senators.

“People can protest with the click of a button,” says Libertarian Party press secretary George Getz. “They can contact their congressional representatives this way, even if they don’t know who they are; all they have to know is their own ZIP code.”

Getz notes that the impact of Internet protest on Congress “is the same in the sense that each e-mail counts the same as a letter or phone call. But it’s simply easier for us to mobilize support this way.”

A Libertarian Party press release claims that StopTheWarNow.com is already generating 1,000 anti-war e-mail messages a day. The Internet “has helped tie together the anti-war movement,” Getz says. “That wouldn’t have been possible without the Net.”

The Internet seems to have made protesting easier for everyone, regardless of political orientation or geography. Len Strazewski, coordinator of computer-assisted reporting at Columbia College Chicago and a widely published Internet expert, points to Eurobasket.com as an example, where “Yugoslavian professional basketball players and coaches have called for the support of all American and European players against the U.S. bombings in Kosovo.

“This protest and others like it,” Strazewski, 44, says, “reflect the way the Internet allows small and often ignored voices to be heard and diverse, dispersed groups to come together and share their opinions.”

Another good example of this is Protest.Net, a site which lists “progressive and leftist protests, meetings, and conferences worldwide” to “help resolve logistical problems that activists face in organizing events with limited resources and access to mass media.”

Run by the ambitious “Rabble-Rouser,” in real-life Evan Henshaw-Plath, a 22-year-old computer programmer from Amherst, Mass., Protest.Net attempts to join the virtual protests on the Internet with in-the-streets protesting. For example, the site features news about a “national march on the Pentagon to end the war,” set for June 5.

“Implicit in the real world protest is the threat of people rising up and taking the power in to their own hands,” says Henshaw-Plath, discussing the differences between the two. “Online protests are much more focused on the fight for ideas … people can use the Internet to provide a forum for in-depth discussion.”

In that vein, Protest.Net has partnered with the Z Mag Network to provide a leftist, anti-war viewpoint on the conflict in Kosovo.

The people behind the MomentofSilence.org, meanwhile, claim to eschew any particular point of view on the Kosovo matter in their efforts to organize a worldwide moment of silence for peace in the Balkans.

“This is not a statement against the United States, or against the Kosovars, or against the Serbians,” the Web site says, although it links to each of the aforementioned anti-war Web sites. “It is about the value of individual human life and liberty. It is a gesture of peace and good will for all men, women, and children.”

MomentofSilence.org asks users to participate by entering their name (or alias) and hometown, along with any comments. Webmaster Chris Whitten, 27, views the site as “a way to encourage people to think about the Yugoslavians and especially the Serbians as human beings. It’s sort of outrageous on the news when you hear them talked about as collateral damage.”

More than 25,400 people seemed to agree, pledging to observe two minutes of silence at 11 a.m., Chicago time, on May 24. Whitten estimates that the number of actual participants was two to three times the number who signed up, representing people who observed the moment of silence with their families or in prayer groups. The Web site itself went completely black when the moment came.

Among those who pledged were Rep. Ron Paul (R-Texas) and the only Serbian-American in Congress, Rep. Rod Blagojevich (D-Ill.) of Chicago. The Web site is still active, and since May 24 close to 4,200 more people have signed up, observing a moment of silence on their own.

“It is different,” Whitten says of the Moment of Silence campaign. “It’s one of those things that could never have been done before the Internet. This is not being led by big media or big religion or big politics, it’s just people.”