By David Clarke, CQ Staff

March 16, 2009 -- As the congressional budget panels prepare to write their fiscal 2010 blueprint, members of the Blue Dog Coalition of fiscally conservative Democrats want to make sure that any expansion of health care coverage is fully paid for—and that its tax or spending offsets are guaranteed to yield savings down the road.

Leaders of the 51-member coalition wrote to the House and Senate Budget committees as well as congressional leaders stating their support for President Obama's goal of offsetting the cost of a planned health care overhaul. But the Blue Dog leaders said they do not want the savings to be achieved too far in the future if new spending in the short term is going to exacerbate already high federal deficits.

"While we agree that reforming our health care system will eventually lead to savings, it would be irresponsible to take on additional large-scale deficit spending in the short term without the ability to definitively quantify future savings," Blue Dog leaders wrote March 13 in a two-paragraph letter.

The Blue Dogs are major boosters of the congressional "pay as you go" budget rule that requires new mandatory spending or tax cuts to be fully offset with increases in revenue or spending cuts elsewhere. The rule was put in place during the 110th Congress to signal Democrats' concern about rising deficits.

But as Congress has passed financial bailout and economic stimulus laws in recent months, the deficit has jumped sharply, with the Obama administration estimating that it will total $1.8 trillion this year, a post-World War II record.

In his budget, Obama proposed establishing a $634 billion reserve fund as a "down payment" for policies to expand and improve health care coverage. He proposes fully offsetting the cost of this fund by reducing the amount of money high-income taxpayers can deduct from their tax bills—which the administration estimates will bring in an additional $317.8 billion in savings over 10 years- and by making changes to the Medicare and Medicaid programs.

But the idea of limiting tax deductions has already run into resistance from key congressional Democrats, and there are some questions about how much the proposed changes to Medicare and Medicaid will save—and when that savings will occur.

The budget proposes a variety of ways for finding savings in the Medicare and Medicaid programs, such as requiring wealthier participants in the Medicare drug program to pay more their prescriptions, encouraging hospitals to lower their readmission rates and making cuts to Medicare Advantage, a program in which private insurers provide Medicare benefits. Overall the administration estimates this part of the proposal would save $316 billion over 10 years.

Most of the savings from Medicare and Medicaid would be achieved in the second part of the 10-year window presented in the budget. During the first five years the administration estimates that only $83.7 billion of the $316 billion in savings would be achieved. This lag that is what concerns the Blue Dogs and some other Democrats.

Senate Budget Chairman Kent Conrad, D-N.D., who says he supports efforts to overhaul the health care system this year, has expressed concerns about expanding the amount spent on these programs as well as waiting too long to pay for new policies.

"When I hear we aren't going to see any savings for 10 years I become skeptical," he said last week.

In hearings Peter R. Orszag, the director of the White House Office of Management and Budget, has defended the ideas in the president's budget for wringing savings from Medicare and Medicaid as being among the best ideas offered by government analysts and academics.

"I think we're as forward-leaning as you possibly can be in investing in health [information technology], comparative effectiveness, changing incentives for providers, investing in prevention, and I'd welcome other suggestions, because I think that is the whole ball game," he told the Senate Budget Committee on March 10.

Many industry and advocacy groups, meanwhile, have urged the Budget committees not to insist that health care legislation be fully offset over 10 years. Several groups wrote a letter to the committees earlier this month, arguing that savings from an overhaul will only be evident as new policies have time to work. The list of signers included the U.S. Chamber of Commerce, the Pharmaceutical Research and Manufacturers of America, AARP, the AFL-CIO and hospital, physician, and patient advocacy organizations. The Blue Dog letter is, in part, a response to these groups.

Paul M. Krawzak and Drew Armstrong contributed to this story.

By John Reichard, CQ HealthBeat Editor

March 20, 2009 -- Harvard Medical School professor David Blumenthal, named Friday by the Obama administration to head federal efforts to spur the adoption of health information technology, says that federal funding, hand-holding "geek squads" to help doctors and hospitals learn how to adopt and use the technology, and performance-based payment systems are key to overcoming formidable national obstacles to adoption of health IT.

Blumenthal said in an e-mail message Friday that he will "keep his powder dry" about his plans for his first weeks in office until after he starts in mid-April as National Coordinator for Health Information Technology. But in an article written in January for the Commonwealth Fund, Blumenthal detailed his thinking about the challenges the federal government faces in spurring the nation's laggardly adoption of electronic health records (EHRs) and computerized "decision support" software that prompts doctors to make the best medical choices.

Blumenthal's analysis preceded the economic stimulus law (PL 111-5), which provides billions in new spending on health IT, and so did not directly address its provisions. But Blumenthal noted the great fear even among health IT supporters that spending billions may not lower costs or improve public satisfaction with health care. "The great dangers are that providers will acquire EHRs, but those EHRs will not have the computerized decision support that makes them effective," he wrote. "Or they may have the necessary capabilities, but providers won't know how, or be motivated, to use them."

"To avoid this, at least three things must happen," Blumenthal said. "First, the vendors of records must produce user-friendly systems that have the ability to improve provider performance; federal certification would help in this regard. Second, tech-averse providers will need a lot of hand holding" through "geek squads" formed locally by creating HIT-support organizations using federal grants or loans. "Third, and perhaps most important, the health care system will have to reward—or force—providers to improve their performance, so that they will be motivated to buy capable systems, get the help they need, and use the systems to full capacity."

The economic stimulus law provides for net additional federal spending of $19 billion for health information technology, including $2 billion in discretionary funds and $17 billion for investments and incentives offered through the Medicare and Medicaid programs to help increase the use of the technology in hospitals, doctors' office and other medical facilities. The law requires the government to lead the development of standards by 2010 that would allow health information to be exchanged nationwide. The money will initially boost Medicare payments for providers using IT, but by the fifth year, payments to providers will be cut if they don't use the technology.

While the money addresses some of the financial challenges, Blumenthal noted in his January article that the payoff from health IT comes from "computerized decision support, which, in its simplest form, reminds clinicians to get needed tests or provide certain treatments . . . But decision support can do even more. It can let a doctor know which diabetics need to increase their insulin or to adjust drug dosages in special situations," Blumenthal said. "Unfortunately, many existing commercial software systems lack such capabilities."

But only about 17 percent of U.S. doctors and 8 percent to 10 percent of U.S. hospitals have at least a basic electronic health record, Blumenthal said. In most European countries, 80 percent to 100 percent of primary care doctors have electronic health records, he added. While some experts argue that its better to take a "bottom up" approach that improves software in the United States before spending billions to encourage providers to adopt imperfect systems, "a counterargument is that doing this amounts to letting the perfect be the enemy of the good," Blumenthal noted.

"Countries around the world are adopting existing systems to good effect, and here in the United States a number of health care organizations, such as Kaiser Permanente, Geisinger Health System, and the Marshfield Clinic have done the same thing. Existing EHRs could be better, but while we wait for a bottom up approach to work (if it does), we will sacrifice important opportunities to save money and improve quality of care."

Blumenthal brings policy expertise to the challenges he faces more than nitty gritty systems expertise. Writing for the technology news Web site ZDNet, business journalist Dana Blankenhorn said of the Blumenthal announcement, "what we have is someone who knows what needs to be done rather than someone who knows how to do it."

David Brailer, who held the health IT coordinator's position during the Bush administration, agreed that Blumenthal "is not a geek—thank God."

"I don't think this is a job for a geek," said Brailer, who said he is "delighted" with the Blumenthal appointment because he is "remarkably prepared" for policy challenges like assuring medical privacy and figuring out how Medicare payments should be changed to spur IT adoption. Blumenthal also has organizational savvy, Brailer said. "He understands how you get things done and build organizations."

One of the biggest will be figuring out what constitutes "meaningful use" of health IT, the standard for receiving added Medicare money, Brailer said. The term has to be defined and a way to measure it has to be developed through extended rulemaking likely to generate 7,000 to 12,000 comments, Brailer predicted. All of that has to be done in time for fiscal 2011, which begins 18 months from now.

"It's an unprecedented policy shift in how doctors are paid," according to Brailer. He said the actual money going out the door is $34 billion, not $17 billion, which he calls a net figure. The $34 billion will generate $17 billion in savings, resulting in the $17 billion net figure, Brailer said.

How much money will be enough is unclear. A recent analysis by the consulting firm Avalere Health suggested that some doctors might be better off financially not investing in health IT, despite the noncompliance penalty.

Among the longer-term challenges Blumenthal faces is the cost of creating a national network for the exchange of health data. Blumenthal and other analysts estimated in an Augut 2, 2005, article in the Annals of Internal Medicine that a national network would require $156 billion in capital over five years and $48 billion in annual operating costs.

But for now Blumenthal is likely to enjoy strong industry and Capitol Hill backing as he takes on IT challenges. Senate Health, Education, Labor, and Pensions Committee Chairman Edward M. Kennedy, D-Mass., said in a statement Friday that "President Obama has made an inspired choice in selecting David Blumenthal to lead the Administration's effort to bring health care into the digital age. David is the right person to oversee this major initiative to reduce costs, avoid errors, improve care, and save lives." Blumenthal, a medical doctor, was a member of Kennedy's health staff from 1977 to 1980. In addition to his Harvard professorship, he also is currently director of the Institute for Health Policy at Massachusetts General Hospital in Boston.

The American Health Information Management Association said "there is not a more appropriate selection" than Blumenthal.

By Drew Armstrong, CQ Staff

March 19, 2009 -- The top Republican on the Senate Finance Committee says the toughest single issue confronting lawmakers drafting a health care overhaul is whether to create a government-run insurance option to compete with private health insurers.

"This is a deal breaker for Republicans if it's in, and it's a deal breaker for Democrats if it's not," Charles E. Grassley of Iowa said Thursday of the public plan option. "Is there a compromise in between? I don't see one today. There might be one. If you're going to negotiate in good faith, everything's on the table. But it's one of the most difficult things, and I don't see a compromise in that area."

But it could be worse, he said. "I told you that abortion is about the only issue I know of that's not compromisable."

Grassley repeatedly said that although he cannot currently envision a way to resolve the dispute, he would not write off the public-plan option as an absolute deal breaker, in order to keep making progress. "I'm positive we can get health care reform done," he said.

Democrats have pushed for a government-run plan to be among the options available to Americans seeking health insurance, and President Obama has mentioned it as well. A public plan, as imagined, would compete with private insurance plans as a way to cover the nation's 46 million uninsured people.

Many Democrats argue that a public plan that competes with private insurers is the only way to force down overall costs. Republicans, meanwhile, argue that it would be unfair competition, eventually driving private insurers out of business. "I think it's a step to single-payer," government-run health care, Grassley said.

Grassley made his comments as part of a round table hosted by the Kaiser Family Foundation, where he laid out how discussions on a health care overhaul have been going and what issues are becoming problematic.

Senate Finance Chairman Max Baucus, D-Mont., has proposed expanding existing public programs and perhaps creating an early buy-in for Medicare, along with a public-plan option. Pete Stark, D-Calif., chairman of the House Ways and Means Subcommittee on Health, has made similar suggestions.

Still, Grassley has not wavered in pushing for fast action on health care. "I think if it isn't done this year, it won't be done for the next four years," he said.

And he reiterated a position Baucus has taken, urging regular order for a bill and not use of the fast-track budget process known as reconciliation, which would allow Democrats to circumvent a filibuster. "Politically, to have a bipartisan agreement, it's gotta be done through regular order and not reconciliation," Grassley said.

Doctors' Pay
Overhauling the way Medicare pays doctors and hospitals will almost certainly be another challenge. Repeated studies by the Dartmouth Atlas project have shown wide variation in Medicare costs to achieve the same outcomes. White House Budget Director Peter R. Orszag has pointed to such disparities as a potential source for hundreds of billions of dollars in savings.

Rearranging payments would almost certainly upset many physicians, who have proven to be a powerful lobby and one of the key constituencies in keeping a health care overhaul bill alive.

"It's probably something you can do in an overall health reform bill," Grassley said. "It's not something you can do if we don't get this bill passed. . . . It's gotta kind of be lost in the overall issue."

Tax on Health Benefits
Grassley also discussed proposals to put a cap on the tax exclusion for health benefits provided through an employer. Currently, employees pay no tax on their benefits. Some economists argue this has served to drive up health insurance costs while holding down wages.

Democrats have previously attacked proposals to cap the tax exclusion, but Baucus and other lawmakers now seem to be looking at it.

"This is an 800-pound gorilla in the room," Grassley said. "It's an issue that Sen. Baucus has spoken out on, got some criticism; it's something the White House had spoken out on and pulled back a little bit. . . . It's something that's on the table."

One solution might be to cap the exclusion for those at higher income levels and create a new tax benefit for people buying insurance on their own. Currently, they do not receive a tax break for doing so.

Baucus has also discussed putting a cap on the tax exclusion as a potential revenue-raiser and a way to keep health care costs down.

"If we do something in that area, it's got something to do with savings as well as raising money," Grassley said.

By Adriel Bettelheim, CQ Staff

March 17, 2009 – President Obama vowed Tuesday not to scale back his health care, education, or environmental initiatives during debate on the fiscal 2010 budget, despite the prospect of higher deficits and wariness in Congress.

Following a private White House meeting with Senate Budget Chairman Kent Conrad, D-N.D., and House Budget Chairman John M. Spratt Jr., D-S.C., Obama renewed his push to get Congress to adopt a budget resolution that would make room for his priorities. He said that his expansive budget is necessary to provide "an economic blueprint for the future."

Obama said, "With the magnitude of the challenges we face right now, what we need in Washington are not more political tactics—we need more good ideas. We don't need more point-scoring—we need more problem-solving."

Obama challenged his critics to offer "constructive, alternative solutions."

The $3.55 trillion budget proposes costly expansions of health care and education, and a continuation of the government's role in protecting financial markets. It projects a $1.17 trillion deficit for the fiscal year that begins Oct. 1—a reduction from the $1.75 trillion in red ink expected for the current fiscal year.

The budget calls for creation of a "reserve fund" of $634 billion over 10 years to cover an expansion of health care coverage. It also proposes enacting a cap-and-trade system on carbon emissions that would raise $646 billion in revenues, $120 billion of which would be dedicated to renewable-energy programs.

Obama is preparing for a tough fight, and acknowledged as much when he alluded to "some numbers with respect to the budget that may make this even tougher in the coming couple of weeks."

The Congressional Budget Office is expected to release its scoring of the president's plan this week.

Many details of Obama's plan have not been fleshed out, including how he would tier income tax brackets, the details of his cap-and-trade system, and his ideas for cracking down on offshore tax avoidance by U.S. corporations.

But the broad principles are clear. To help pay for the health care reserve fund, Obama would increase revenue by about $318 billion over 10 years by reducing the value of itemized deductions claimed by taxpayers in the top two income tax brackets. That proposal, in particular, has met substantial criticism on Capitol Hill, including from many Democrats.

Meanwhile, as the Budget committees prepare to start work on drafting a fiscal 2010 budget resolution, House Majority Leader Steny H. Hoyer, D-Md., said Tuesday that Democratic leaders are still weighing the option of using the budget reconciliation process to advance Obama's initiatives.

That fast-track process allows legislation drafted pursuant to an adopted budget resolution to pass the Senate by a simple majority, with limited debate, avoiding the need to muster 60 votes to overcome a filibuster.

Hoyer noted there is a lot of resistance in the Senate against using the process for an overhaul of health care. But he also pushed back against the idea that reconciliation should be used solely for legislation whose primary purpose is to reduce the deficit.

"The real purpose of reconciliation is to try to get, not so much our policies, but the policies of the majorities of both houses," he said. "That's seems to be a concept that has alluded many that in America the majority rules."

House leaders have been frustrated by the Senate's inability to move the Democratic agenda in recent years. Democratic leaders have often been unable to assemble the 60 votes needed to avoid Republican filibusters.

There also is resistance to moving a cap-and-trade bill through reconciliation. Last week eight Democrats and 25 Republicans in the Senate wrote the Budget Committee requesting that the expedited process not be used for a climate change bill.

By John Reichard, CQ HealthBeat Editor

March 17, 2009 -- Democrats who want universal health coverage will need all the savings they can get to pay for it, so it was no surprise on Tuesday when House Ways and Means Health Subcommittee Chairman Pete Stark, D-Calif., said he favored backing all of the recommendations issued by the Medicare Payment Advisory Commission (MedPAC) to reduce Medicare spending compared to current law.

"I hope that we follow all of the MedPAC recommendations and save some money," Stark told reporters after a hearing by his subcommittee on the advisory commission's March 1 payment recommendations to lawmakers. The hearing on MedPAC's payment advice is an annual event, but a Stark aide described it as part of a series of hearings this year on overhauling the health care system. Stark said those hearings will run until May and that after that his panel will mark up legislation overhauling health care.

While tax changes are on the table to raise some of the money to cover the uninsured, Medicare savings are part of the mix. President Obama, for example, has called for cuts in spending on Medicare Advantage plans, home health agencies, and some elements of hospital care to pay for covering the uninsured. Stark said Tuesday that "Medicare improvements" must be part of a health overhaul.

MedPAC Chairman Glenn Hackbarth testified that the commission favors increases for hospitals, doctors, ambulatory surgery centers and dialysis facilities in fiscal 2010, payment rate freezes for skilled nursing facilities and inpatient rehabilitation facilities, and payment reductions for home health agencies.

But MedPAC and those who favor its recommendations now face a barrage of complaints by providers and their allies on Capitol Hill that squeezing payments below levels in current law will harm access to care and water down its quality. Stark noted as much in his opening remarks, saying that "many in the provider community will balk at the recommendations," and that MedPAC's advice too often gets twisted up in complaints by providers that they can't sustain payment revisions that don't match increases in Medicare "market baskets" measuring changes in the cost of delivering care.

But Stark made a pitch for heeding MedPAC's advice, saying the panel "is as representative a board as I think we could find" of the various interests in the nation's health care system. Hackbarth too emphasized the commission's credentials. "The point I want to make is for the most part we are from the health care system," he said, noting that of some 350 commission votes cast on 22 payment recommendations only four were "no" votes and three were abstentions. MedPAC isn't beyond error but its mistakes do not result from a lack of experience in the health care system, he told lawmakers.

Republicans, however, were critical of MedPAC's advice that payments to private health plans should be the same as for fee-for-service providers in Medicare. And they criticized Medicare's payment rates as being too low, and as indicating the enormous financial pressure hospitals and doctors would face if a public program option were added to a system of universal coverage.

The subcommittee's top Republican, Rep. Wally Herger of California, described Medicare payment rates as being sharply lower than those in the private sector, claiming that they are some 40 percent lower in the case of physicians and 30 percent lower in the case of hospitals. Calling that a "huge disparity," Herger voiced disbelief at the idea that the difference didn't result in providers charging private payers more as a result.

Does MedPAC not see cost shifting as a result, with providers charging private insurers more to make up that difference, Herger asked Hackbarth.

Hackbarth's response was that MedPAC's recommended payment rates are sufficient if providers deliver care efficiently. Herger pressed Hackbarth further, asking whether the Medicare rates would be sufficient if there were no private insurers making higher payments. Hackbarth said they would.

The MedPAC chairman noted that recent analyses by the commission show that hospitals under cost pressure are able to tighten their belts to deliver efficient, quality care under Medicare payment rates. In general, hospitals aren't run efficiently because of overly generous private insurance rates, Hackbarth said. "Our concern is overly generous private payments drive up costs," he said. Medicare has to find ways to become more efficient if the program is to be sustained financially, he emphasized.

Higher Medicare payment rates wouldn't necessarily lead providers to charge other payers less, Hackbarth suggested. "It's not at all clear to me that higher Medicare rates would result in lower rates" to private insurers, he said. "For profit hospitals will seek to maximize their profits. Not-for-profit hospitals will seek to maximize their revenues, so they can do good things with it."

By John Reichard, CQ HealthBeat Editor

March 19, 2009 -- The conversation heated up this week in Washington over comparative effectiveness research—but it proceeded in very different ways in different parts of town.

On Capitol Hill and outside Union Station earlier in the week, Consumers Union, publisher of Consumer Reports, trumpeted the research in its very practical, straightforward way, distributing a "Best Drugs for Less" edition of the magazine that names alternatives to high-priced drugs and says "these aren't the least expensive drugs, they're the best ones."

Meanwhile, over at the Humphrey Building, Health and Human Services officials too sought to call attention to comparative effectiveness studies, announcing Thursday the names of members of a new council to oversee a part of the $1.1 billion in such studies funded by the economic stimulus package recently signed into law by President Obama. But there, officials danced away from the obvious—that payers might use the findings as the basis of coverage decisions, in many instances, perhaps, to cover lower cost products and services.

The point of the research, said Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy and HHS senior adviser Neera Tanden, is to arm doctors and patients with information to help them pick the best treatment for a particular medical condition. When a reporter asked Clancy whether she expected payers to use the findings, she wouldn't bite. "How it will be used I don't think we can talk about until we have more information," she said.

Clancy emphasized that the work her agency has done in recent years to identify the best treatments rarely, if ever, points to one approach as being great and another terrible. "It's much, much, more nuanced than that," she said.

In the months leading up to the current overhaul debate, Democrats and Republicans were more likely to refer to the studies as one of the few approaches with a real chance of bringing down spending growth without harming medical outcomes. Peter Orszag, then the director of the Congressional Budget Office and now the White House budget director, said using financial incentives to encourage doctors to use services and products identified by the research as the treatments that work best would eventually bring down spending growth.

But as the overhaul debate has gotten under way, criticism is becoming more vocal that the research could be used to ration care. A week ago, a coalition that said it represents manufacturers, patients, doctors, and certain medical researchers, called bureaucrats making decisions on comparative effectiveness research, or "CER," a "recipe for disaster."

If big payers deny coverage of less cost-effective products it could thwart innovation and medical progress, said members of the coalition, called the Partnership to Improve Patient Care. And the research may be misused to deny access by minorities and the disabled to needed treatments, said the coalition.

Tanden, counselor to the office of the HHS secretary, emphasized that the 15 federal employees named to the new "Federal Coordinating Council for Comparative Effectiveness Research" represent the interests of minorities and the disabled. She said the council wants the research to look at people in "sub-populations," including minorities, the disabled, and people with mental illnesses.

HHS said in a press release Thursday that the council "will not recommend clinical guidelines for payment, coverage or treatment." It will offer office on research priorities for the $400 million in stimulus funds allotted to the office of the HHS secretary for comparative effectiveness studies while coordinating with AHRQ and NIH and their research under the stimulus legislation. AHRQ gets $300 million and NIH $400 million.

Members include Garth N. Graham, HHS deputy assistant secretary for minority health, Michael Marge, acting director of the HHS Office on Disability, and Peter Delany, director of the Office of Applied Studies at the Substance Abuse and Mental Health Services Administration. Other members include representatives of the National Institutes of Health, the Veterans Administration and the Department of Defense, along with Clancy, Tanden, and Ezekiel J. Emanuel, special adviser for health policy at the White House Office of Management and Budget.

By law, membership of the council is limited to federal employees. But HHS spokeswoman Jenny Backus said in the news release that "President Obama is committed to openness and transparency and the Coordinating Council will host open meetings and a listening session as it begins its important work." Clancy said that the first listening session will be held April 14 but dates for other meetings haven't been announced. The council along with NIH and AHRQ faces a July 30 deadline for completion of an "operations plan" for the $1.1 billion in research.

Lobbies representing manufacturers responded politely to the announcement naming council members. "The economic stimulus law made an important footprint in the health care debate by providing significant funds" for the research, said Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America. "As the Administration continues to implement this initiative, we expect it will be done with transparency, openness, accountability and public input in how research priorities are set," added Johnson.

Tony Coelho, chairman of the Partnership to Improve Patient Care, praised the inclusion of representatives of the minority and disabled communities. If the council "provides all health care stakeholders with a voice at the table and focuses on patient needs, our health care system will be well on its way to reform that benefits all Americans."

But Rep. Wally Herger of California, the top Republican on the House Ways and Means Health Subcommittee, issued a statement late Thursday saying "this is yet another incremental move by supporters of government run health care to take medical decisions out of the hands of doctors and patients and put them in the hands of bureaucrats." Herger said he will introduce legislation to "ensure that patients are protected."

But Consumers Union in its new publication described comparative effectiveness research as a way to get patients information on the best drugs while saving individual consumers "hundreds to thousands of dollars a year." It gave advice on lower cost alternatives for some 20 common medical conditions, emphasizing that the advice "is not meant to replace your doctor's judgment." So "use this guide to help you talk with your doctor, not as a substitute for his or her advice."

Consumers Union issued a warning about the dangers of not giving the public information on proven, cost-effective alternatives, releasing the results of a new poll that found 28 percent of Americans take "potentially dangerous actions to save money, such as not filling prescriptions, skipping dosages, and cutting pills in half without the approval of their doctor." Subway passengers exiting the Union Station metro stop near the Capitol were given copies of the "Best Drugs for Less" edition and a display inside the train station featured giant pills running on treadmills to underscore the point that drugs need to be compared rigorously to determine how they stack up against each other.