Why didn't the president vigorously defend health care?

By Robert Field, law and public health professor at Drexel University

President Obama uttered almost 7,000 words in his State of the Union address Tuesday night. By my count, he directed only 208 of them to health reform. That's about 3 percent of the speech focused on his signature policy initiative.

He used almost a third of those 208 words not to tout the law's benefits but to concede its shortcomings. Here's how he began: "So let me be the first to say that anything can be improved."

What gives?

Maybe he wanted to avoid an extremely divisive issue to promote his theme of conciliation and bipartisanship. Republican attempts to repeal health reform have created the deepest partisan split so far in the new Congress.

Or, maybe he thought that other issues were more important. He wants to focus now on creating jobs and enhancing American competitiveness.

Or, maybe he wanted to distract attention from an initiative that many Americans still oppose. Some polls show that close to half the population continues to see the health reform law as a bad idea.

If this was his goal, he may have miscalculated.

While many people dislike the law, most polls show that only a minority favor repeal. The reasons aren't entirely clear, but it seems likely that many people do not want Congress to revisit last year's battles. They may also want to give the law a chance to work before throwing it on the scrap heap. And many of those who disapprove of the law are against repeal because they want health reform to go further.

In fact, many parts of the law remain highly popular, especially the consumer protections. A large percentage approve even of the law's most controversial provision, the mandate that requires everyone to have health insurance, when it is placed in context. While most give the mandate a thumbs down when they are asked about it in isolation, opinions are more evenly split when pollsters present it as a necessary element in forcing insurers to cover everyone.

Voter reactions to health reform played an important role in last fall's election. Neither Obama nor fellow Democrats said very much about the law, and the results didn't go their way. Health reform is likely to remain on voters' minds in 2012. You'd think the president would be doing more to bolster public support.

It's hard to build enthusiasm for an initiative whose creators won't even come to its defense. Republicans are impassioned when they attack health reform. Everyone can sense it. If President Obama wants the issue to play out differently in 2012 than it did in 2010, he needs to show the same fervor.

The public seems ready to hear what he has to say. He just has to say it.

By Michael R. Cohen, president of the Institute for Safe Medication Practices

In a "Check Up" blog posting last July, readers were alerted to the growing problem of prescription drug shortages. More and more, hospitals have been running out of critically important drug supplies, and doctors and pharmacists are being forced to use unfamiliar and often more expensive alternatives.

The lack of experience with alternative medications creates a potential for medication errors and less than ideal patient outcomes. A survey we did last summer showed that the problem has rivaled the situation in Third World countries. Until now, shortages have mainly affected injectable drugs in hospitals and, in most cases, consumers have either remained unaware or haven't seemed too concerned.

But last week a couple of announcements may have changed that.

First, the shortage situation received a lot of publicity when Hospira, the sole U.S. supplier of Sodium Pentothal (thiopental), announced that it would no longer manufacture the drug. The reason for the media attention is that the drug is part of a three-drug combination used in executions in the 34 states that use lethal injection for capital punishment.

Executions are expected to be delayed for weeks or months as court orders are obtained or statutes are changed to allow alternatives. There had already been an ongoing shortage of Pentothal due to production problems at Hospira's North Carolina plant. The company had planned to manufacture the drug at a state-of-the-art plant it owns in Italy, now the only Pentothal production facility in the world. However, Italian authorities told Hospira that they would not release the drug if it could potentially be used in executions. Although Hospira has steadfastly opposed use in capital punishment, the company was unable to guarantee that it would never reach prisons through unauthorized channels. Not wanting to risk a shutdown of its plant in Italy, Hospira stopped making the drug.

Of direct importance to consumers is the fact that Sodium Pentothal is a very important agent in anesthesia. Anesthesiologists consider it a first-line drug in many situations, including patients for whom the side effects of other medications could lead to serious complications.

Referring to its discontinuation because of use in lethal injections, a statement by the American Society of Anesthesiologists reads, in part, "It is an unfortunate irony that many more lives will be lost or put in jeopardy as a result of not having the drug available for its legitimate medical use."

The other announcement last week will affect many consumers more directly. The manufacturer of Tamiflu (oseltamivir), an important drug for treatment or prevention of influenza in children over one year old and adults, announced that supplies of the suspension form of the drug are currently exhausted due to increased demand during the flu season. The company also said it was unable to estimate when the drug will again be available. The suspension is used in children and adults who can't swallow the capsule form. Tamiflu is also available in capsule form.

Although supplies of the suspension may still be available at your pharmacy, a similar problem arose last year, and pharmacists eventually were forced to compound the suspension from powder in the capsules. Beside the fact that prescriptions will likely cost more for compounded versions, for some strange reason the formula that FDA approved for the pharmacy-compounded suspension is more concentrated than the company-made suspension product (15 mg/mL vs. 12 mg/mL).

Since doctors usually just prescribe liquid medicines in volume measurement, such as how many milliliters (mL) or teaspoons you should take, there will be confusion regarding how much liquid of the pharmacy-made medicine to take in order to get the intended mg amount. I am aware of incidents in which doctors expecting the 12 mg/mL product were unaware of the shortage and did not know a 15 mg/mL concentration was being supplied.

The last time this happened, even doctors themselves were confused into taking the wrong amount. A New England Journal of Medicine letter on Sept. 23 describes a case in which a couple, who were both health professionals, were dumbfounded by the labeling when trying to prepare a dose of the medication for their child.

The Tamiflu situation is a good example of how a drug shortage contributes to dosing errors. Except this time it's hitting home.