For some veterans, the fight didn't stop on the streets of Iraq or in the mountains of Afghanistan. Despite the promise that world-class medical care would be there for them when they arrived home, some are running into a bureaucratic battlefield and a stressed system struggling to give aid.

Recent congressional and public attention has focused on access problems at the Dept. of Veterans Affairs, which provides medical care to servicemen and women once they have left active duty in a time of war or an official period of hostility. Although investigators note that improvements are under way, they say the VA has a long way to go.

Nearly 700,000 active-duty personnel and reservists who served in Operation Iraqi Freedom and Afghanistan's Operation Enduring Freedom have been eligible for VA health care since 2002. More than 200,000 have sought it out so far, the Congressional Budget Office reported in October. While this represents only a small fraction of the nearly 8 million veterans from all conflicts who are enrolled, the impact of veterans from today's wars on the system is great.

Thanks to recent advances in battlefield medicine, more servicemen and women are surviving severe injuries, CBO said. But they require more costly medical care when they return. The rapid influx of new enrollees has helped strain a system that already was under pressure from caring for the veterans of yesterday's wars. In 1995, fewer than 3 million veterans received VA health services. That number had increased to 5 million last year.

Many of the resulting access problems start at the very beginning of the enrollment process, said Donna E. Shalala, PhD, president of the University of Miami and former Dept. of Health and Human Services secretary. She co-chaired a presidential commission on care for America's "wounded warriors" that convened earlier this year after news reports exposed substandard conditions and a mass of red tape at Walter Reed Army Medical Center in Washington, D.C.

Although the Dept. of Defense and VA need to work together to foster a patient-centered continuum of care for each veteran, the commission found evidence that returning personnel were not experiencing a smooth transition from military health care to the veterans system, Dr. Shalala said.

There are nearly 8 million veterans in the VA system.

Without designated care coordinators to plan the best treatment path for new patients, an untold number ended up lost.

In addition, injured combatants must go through two antiquated disability assessments -- one by the military and one by the VA -- to determine what treatment options are available. This means that many are forced to jump through bureaucratic hoops that might not even get them to the right place, Dr. Shalala said.

"For veterans' families to give up everything just to coordinate this care themselves is fundamentally unfair," she said. "The process is too old-fashioned. It has nothing to do with modern medicine, and we ought to be embarrassed."

The Bush administration scrambled to correct several problems identified in the commission's July report. The Defense Dept. and VA in October agreed on an initial plan to place at least 10 care coordinators at four military medical sites that often serve as the first stop for wounded veterans. The Army also announced in October the formation of "warrior transition units" consisting of primary care physicians, nurse case managers and mental health professionals that would serve a similar purpose.

But Dr. Shalala said progress is still slower than she would like, and some of the commission's recommendations would require tough congressional action. The proposal to consolidate and modernize the disability review process, for instance, quickly became mired in partisan bickering.

Delays and headaches

For veterans who make it through the VA's bureaucratic gauntlet, the care they need might not be immediately accessible or available.

The department has more than 150 hospitals and nearly 900 outpatient clinics. While the number of facilities has increased in recent years, it is not nearly enough to provide VA services everywhere in the country. Many patients in rural or remote areas must travel hundreds of miles to reach the nearest department facility -- an impossible prospect for many.

The VA has more than 150 hospitals and nearly 900 outpatient clinics.

Jeffrey Scavron, MD, a former Navy doctor who practices at a community health center in Springfield, Mass., has seen this problem firsthand. Veterans in his area can get basic services at the Northampton VA Medical Center in nearby Leeds, Mass., but often must travel to Boston or Connecticut if they need to see certain types of specialists through the system. Some simply cannot make the trip and go without the care rather than pay for it, he said.

When veterans decide to stick with the VA, the system does not always respond quickly. Advocacy groups have complained to lawmakers that some enrollees seeking appointments, non-emergency surgeries or other medical care have been placed on waiting lists when facilities have been unable to meet demand.

In recent years, Spokane (Wash.) VA Medical Center implemented waiting lists when lean federal budgets forced it to cut back on services, said Joseph M. Manley, the center's former director. At one point, more than 3,000 veterans were waiting for more than a year just to receive their initial medical appointments.

The VA strives to see all patients within 30 days of when they call for an appointment. Out of the roughly 39 million appointments processed in a year, about 4 million exceed the 30-day threshold, said Michael J. Kussman, MD, the VA's health under secretary. While this leaves room for improvement, the department is proud of its nearly 90% record, especially because these appointments are not for urgent or emergent medical situations, he said. "I'm not aware of people being hurt in any way by some of the delays."

The VA's record is disputed by the department's inspector general, who in September released an audit that found the VA analysis likely understated wait times.

Not enough doctors to go around

Some facilities have little choice but to make patients wait for treatments or to refer them elsewhere because they do not have enough medical personnel. The department has struggled, along with many private health systems, to provide quick access to such in-demand subspecialists as dermatologists, ophthalmologists and otolaryngologists, Dr. Kussman said. Mental health professionals also are at a premium, the VA reports.

Some experts on the ground say the situation can be particularly difficult for the department when it attempts to treat veterans who have complex and specialized wounds, such as traumatic brain injuries -- the signature injury of today's wars.

1.8 million veterans were uninsured in 2004, up nearly 300,000 since 2000.

The VA polytrauma rehabilitation center in Palo Alto, Calif., is touted as a flagship for taking care of the most severely wounded veterans but still faces major staffing concerns. The center works hard to attract and retain physicians and others in a very competitive market, but it has fallen short of recruitment goals for physiatrists and other medical professionals, said its director, Elizabeth Joyce Freeman.

Veterans advocacy groups say the way the VA receives federal health funding is largely to blame for many of its shortfalls. Unlike Medicare and Medicaid, which receive mandatory funding every year based on projected costs, the department gets its money from the discretionary budget. This process is much less predictable and more prone to political tinkering.

Although Congress in recent years has kept up a steady stream of funding that has satisfied many advocates, the process has not been without missteps.

The department weathered an embarrassing episode in 2005 when then-Secretary R. James Nicholson went to Congress with a request for $2.6 billion in additional funding because it had vastly underestimated the number of Iraq and Afghanistan veterans who would require care.

The budget unpredictability makes it hard for VA facilities to plan ahead on hiring physicians or buying equipment, said Joseph A. Violante, the Disabled Veterans of America national legislative director.

Veterans can be waitlisted or shut out as a result.

"If the VA was able to get the funding on time and was able to know beforehand what that funding level was going to be, a lot of those access problems would be solved," he said.

The department opposes mandatory funding because the process would not easily adapt to changes in clinical practice or enrollee demographics, said W. Paul Kearns III, VA chief health financial officer.

Finding care outside -- or not at all

For some veterans, accessing VA health care simply will not be the best option because of their circumstances, locations or the specialized care they need. Some, especially those who plan to return to active duty, will continue to receive care from the military. Others will enroll in private insurance or receive coverage through another government program once they re-enter private life.

The department has boosted the amount it spends on private-sector care for veterans who remain enrolled in the VA but need to receive care outside the system. In fiscal year 2007, the department committed $2.2 billion out of its roughly $35 billion health budget to such fee-for-service care, a figure that has doubled since 2000.

For others, accessing VA health care is not an option at all. In 2003, the Bush administration decided to cut off new enrollment for many Priority Group 8 veterans, the department's lowest disability rating. These veterans are deemed to have sustained no service-connected disabilities and have yearly incomes that exceed predetermined limits, about $28,000 for an individual.

All combat veterans who have served in Iraq and Afghanistan are still guaranteed two years of free VA care after they return, and Priority Group 8 combat veterans who enroll during that window can keep receiving the care beyond that timeframe by making set co-payments. But those who fail to enroll in time risk losing access unless they later can prove they actually sustained a disability during their service.

Lawmakers have proposed extending the free combat veteran care from two years to five years, a move the White House supports. The Bush administration, however, opposes any plan to reopen new enrollment to non-combat Priority 8 veterans because the new enrollees would cost tens of billions over the decade and could hurt access and quality for higher priority patients, Dr. Kussman said.

But as long as this and other barriers exist, veterans who can't afford or obtain private coverage will go without needed care, said Steffie Woolhandler, MD, MPH, a Harvard Medical School professor and co-founder of Physicians for a National Health Program, a single-payer advocacy group. An October study she co-authored concluded that 1.8 million veterans from all conflicts were uninsured in 2004, up nearly 300,000 since 2000. Nearly half of them had not seen a physician in more than a year.

Dr. Scavron, the former Navy physician, said the uninsured veterans he sees in his clinic are evidence that the government is not fulfilling its responsibilities

"It's only the government that can take you into military service," he said. "So it seems to me that it's only the government who can take responsibility for the people that they take into service."

Washington -- A wealthy Maryland county is working on a plan to provide at least basic health care to most of its 15,000 uninsured adults -- a concept that could be reproduced in many counties around the United States, its proponents say.

The proposal, announced by Howard County leaders in October, would provide free primary, specialty and hospital care; personal care plans; and prescription drugs to enrollees. Individuals would pay monthly premiums ranging from $50 to $85, depending on income. These premiums would cover the bulk of the program's $2.8 billion cost.

"We have the opportunity to make Howard County the model health community," said Howard County Executive Ken Ulman, the county's highest elected official.

A few states and even the combined city/county of San Francisco have expanded health insurance coverage or access to health care through comprehensive reforms. But Howard County might be the first county-only government to tackle health system reform in a significant way.

About 20,000 of the county's 275,000 residents are uninsured. That figure includes 5,000 children, the vast majority of whom are eligible for Maryland's State Children's Health Insurance Program. County leaders hope to enroll as many eligible kids in SCHIP as possible by alerting their parents in letters from Maryland's comptroller that their children qualify, said Howard County Health Officer Peter Beilenson, MD, MPH.

The county hopes to enroll up to 12,000 of the 15,000 uninsured adults in the proposed health access program, called Healthy Howard. Many of the remaining 3,000 uninsured adults are likely young and healthy and not interested in paying for health care, Dr. Beilenson said.

Healthy Howard participants would be eligible for up to seven free primary care visits a year at the Chase Brexton health center and free hospital care at Howard County General Hospital. County officials are negotiating contracts with specialist physicians, Dr. Beilenson said.

The heart of Healthy Howard is its health action plans -- an attempt to manage chronic diseases better and improve enrollees' general health. Enrollees would be given one of six priority levels based on their health, with more attention for those with more chronic diseases.

Each participant would see a team of health specialists, including a dietitian, a social worker and a health educator, with whom unhealthier enrollees would have more frequent contact. Those who don't make progress on their health action plan would lose their subsidized access to the hospital, specialty care and prescription drugs.

Healthy Howard has its limits. It's not health insurance and wouldn't help residents traveling outside of the county. It wouldn't cover noncitizens, and -- at least for its first year -- it would be limited to 2,000 residents earning 300% or less of the federal poverty level, Dr. Beilenson said. Also, applicants would have to be uninsured for one year.

"It's not the perfect solution. But it is a model for what national health care reform should include," Dr. Beilenson said. If adopted in the spring as part of Howard County's 2009 budget, the program would begin enrollment on July 1, 2008.

Physicians' early views

Earl V. Wilkinson, MD, an otolaryngologist and president of the Howard County Medical Society, wasn't familiar with the details of Healthy Howard. But Dr. Wilkinson, speaking on his own behalf, said he knows one thing for sure about this type of plan. "You have to pay the doctors, or they're not going to want to participate."

He expects local physicians to give Healthy Howard a wary reaction based on their experiences of caring for people in the state's Medicaid program.

But Dr. Beilenson, who is negotiating contracts with physician specialists, said he's received good feedback. "The physician community has been very positive."

MedChi, the Maryland State Medical Society, hasn't taken a position on the plan yet. Martin Wasserman, MD, the society's executive director, said he is enthusiastic about Healthy Howard. He said Dr. Beilenson, former Baltimore health commissioner, wouldn't back a program that financially straps physicians or increases their administrative work.

"He understands the situation and the problems that physicians are having," Dr. Wasserman said.

Doctors should be interested in Healthy Howard because it doesn't involve insurance companies, he said. Health plans reimburse Maryland physicians at lower-than-average rates, he said. Insurance companies pay doctors there an average of 100% of Medicare rates, compared with 120% for the rest of the nation, according to analyses by the Maryland Health Care Commission and the Medicare Payment Advisory Commission.

A gubernatorial task force recently began examining physician pay and has been asked to submit a final report by June 30, 2008.

Could other counties imitate?

Although Howard County's median household income of $80,904 in 2004 ranks third in the U.S., according to the Census Bureau, other counties could still reproduce a Healthy Howard-type of reform without bankrupting themselves, Dr. Beilenson said.

The county's wealth, in part, makes Healthy Howard possible. The county government plans to contribute $500,000 toward the $2.8 million, first-year budget. That $500,000 represents only 0.06% of the county's $813 million 2008 general fund budget.

But perhaps more important, Ulman -- whose brother is a three-time cancer survivor -- and other Howard county leaders support health care reform, when most county leaders don't see it as a county-level priority.

"It is the political will that is allowing us to go forward. It is not the funding," Dr. Beilenson said.

Many counties might not have some of the resources needed for a Healthy Howard-type plan. For example, the proposal anticipates $700,000 in private donations. More than $200,000 was pledged in the first two weeks after the county unveiled the plan, Dr. Beilenson said.

Dr. Wasserman said it's premature to talk about other counties adopting Healthy Howard. But he believes the plan will be successful because it must be. "If this program doesn't work, it's not a good omen for the future of medicine and health care."

Washington -- Medicare and Medicaid spending would -- if unaddressed -- continue to grow faster than the economy over the next 75 years, but don't blame it all on the baby boomers. Instead, look at the way physicians and hospitals are paid and how technology and new treatments drive costs, according to a first-ever Congressional Budget Office analysis of long-term health spending.

"The main message of this study is that, without changes in federal law, federal spending on Medicare and Medicaid is on a path that cannot be sustained," stated the report, released Nov. 13.

CBO Director Peter Orszag, PhD, said other Medicare and Medicaid spending predictions have overemphasized the effect of the aging American population, including the baby boomers.

"That fact that our population is getting older does affect the federal budget and is a factor in our overall long-term fiscal problem. However, it is not by any means the main factor," Dr. Orszag said. Other factors, such as new technology, play a larger role.

In 2030, federal Medicare and Medicaid spending will consume about 8% of the gross domestic product, a measure of the total value of goods and services produced in the U.S., the report predicts. Of that, 0.8 percentage points would be from the effect of aging. By 2082, federal Medicare and Medicaid spending would eat up 18.5% of the gross domestic product, with the effect of aging representing just 1.7 percentage points.

Dr. Orszag emphasized that CBO estimates are not an attempt to predict the future but are a picture of what would happen if the health system isn't reformed. With that in mind, the CBO report estimates by 2082 overall health spending would equal 49% of the gross domestic product.

Many health system reform proposals call for electronic medical records, which will help reduce costs, Dr. Orszag said, but mostly because the data they will generate will show which treatments are more effective. Those data are coming together slowly so far because only about one-third of doctors and hospitals have electronic records systems, he said.

He said national health reform proposals estimating that EMRs would save tens of billions of dollars per year are "substantially above anything you would see in a CBO [analysis]."

More research needed

Although the CBO predicts massive increases in health spending, that could be reduced by as much as 30% by comparing treatment outcomes, a practice known as comparative effectiveness, and linking it to pay, Dr. Orszag suggested. "It is striking that we spend 16% of our gross domestic product on health care and we do so little to evaluate what we're getting in return for it, specifically in terms of this intervention versus that intervention," he said.

Jim King, MD, president of the American Academy of Family Physicians, agreed. He noted that physicians increasingly are using community-based outcomes data to improve their treatments. But preventive care needs more emphasis, he added.

"We have to change the way we pay for health care. Instead of trying to control costs, we have to try to control quality and outcomes and make sure we are spending money at the right places," Dr. King said.

Dr. Orszag said analyses of Medicare spending by the Dartmouth Atlas of Health Care show that the number of interventions and treatments provided to beneficiaries in their last six months of life, and the resulting spending, varied dramatically among hospitals in different regions, with no difference in patient outcomes. One hospital in California spent twice as much as a hospital in Minnesota -- more than $50,000, compared with just less than $25,000.

"I think what's clear is the additional spending has generated improvements in health outcomes at an aggregate level. But it's also clear that a lot of what we deliver is of dubious value," Dr. Orszag said.

Bruce Bagley, MD, AAFP medical director for quality improvement, said comparative effectiveness is not as important as reforming a payment system currently based on the number of services provided and not the overall health of the patient. "Unless we do something about that, anything else you did is sort of just nipping at the edges," he said.

Also, comparative effectiveness doesn't always conclude that one treatment is better than another, Dr. Bagley said. For example, an Agency for Healthcare Research and Quality study released in December 2005 found that drugs can be as effective as surgery for management of gastroesophageal reflux disease.

Dr. Bagley said one reason for increasing spending is defensive medicine. Physicians are over-relying on medical imaging and tests to protect themselves from liability and because patients expect certain treatments.

American Medical Association President Ron Davis, MD, pointed out that physicians alone can't cure certain chronic diseases, which are major contributors to health spending.

"While physicians play a key role in efforts to contain costs, problems like obesity, tobacco use, alcohol and substance abuse, and violence will require action by stakeholders from inside and outside the health care system to drive major societal change," Dr. Davis said.

Dr. Orszag said personal behavior has a huge effect on health. For example, people eat for more than just sustenance. "There are all sorts of things that have to do with our environment that we have not yet processed or thought about in terms of how it could help us improve health outcomes," he said.

The Illinois cap on noneconomic damages in medical liability cases hangs in the balance, now for the third time.

A trial court struck down the award limit as unconstitutional. A number of other state tort reforms were felled along with it. The Nov. 13 ruling propels the issue directly to the state Supreme Court.

Cook County Circuit Court Judge Diane J. Larsen said the 2005 law -- which limits pain and suffering damages to $500,000 for physicians and $1 million for hospitals -- violates the separation of powers between the Legislature and the judiciary. Her opinion suggests that it's up to the courts, not lawmakers, to decide awards.

In addition, the decision invalidates a host of other reforms included in the statute, because those provisions were inseparable from the cap under the law. Among them, the court voided measures that:

• Increase the affidavit-of-merit requirements.
• Raise standards for medical expert witnesses.
• Allow periodic payments of jury awards by defendants.
• Exclude doctors' sympathy statements from being used against them in court.

The case before the court consolidated three lawsuits questioning the validity of the reforms. At press time in mid-November, Illinois State Medical Society officials said an appeal was imminent, though it had not yet been formally filed. Because the ruling hinges on the statute's constitutionality, the high court automatically would take up the appeal.

Physicians decried the trial court ruling and vowed to fight it.

As they gear up for the court battle ahead, doctors are concerned that Illinois' medical liability climate -- which they say has improved since the 2005 reforms -- will be further endangered if the decision stands.

American Medical Association Board Trustee Robert M. Wah, MD, called the decision "a step backward for Illinois patients and physicians as it once again puts patients' access to care in jeopardy."

Illinois is one of 17 states the AMA has declared to be in crisis because unaffordable insurance premiums have deterred doctors from practicing there. State doctors maintain that the cap has helped repair that.

Illinois State Medical Society President Rodney C. Osborn, MD, said that in the past two years, the state's largest insurer, ISMIE Mutual Insurance Co., reduced rates an average of 5.2% across all specialties, and that competition in general has grown. In that time, the state also received an influx of neurosurgeons and obstetricians in areas where there were few to none of the specialists before, he said.

The court ruling is "just one step in this process, and we are very concerned it has the potential for us to lose physicians and disrupt the improvements we've seen," Dr. Osborn said. "We can't afford to forfeit patients' access to care."

Lawyers support court decision

Meanwhile, plaintiff lawyers said they are equally committed to defending what they view as a part of patients' due process rights. They praised the court's decision and argued that the cap and other reforms amount to special legislation for doctors and hospitals.

"One thing is clear: Our state constitution does not allow those who have been most seriously injured as a result of medical negligence to have their rights taken away," said Bruce M. Kohen, president of the Illinois Trial Lawyers Assn.

Kohen said the recent decision upholds Supreme Court precedent and marks the third time in 31 years that Illinois courts have declared such restrictions constitutionally flawed.

The high court in 1976 struck down a law that limited economic and noneconomic damages in medical liability cases. In 1997, justices threw out a noneconomic damage cap imposed on all personal injury cases, which included medical liability and wrongful death lawsuits.

Medical society officials say the latest measure was carefully crafted to withstand judicial scrutiny. It applies just to pain and suffering damages in medical liability lawsuits.

Whilst the estrogen-like plant chemicals found in soy isoflavones have a vast amount of well-known benefits for women, new research has that soy isoflavones have significant benefits for men too, notably in the form of a reduction in the symptoms of benign prostate hyperplasia (BPH).

Many of the health benefits of soybeans are found in the isoflavones, which have been found in several studies to be effective in the treatment and prevention of many health conditions including breast cancer, heart disease, due to their ability to reduce cholesterol, and particularly menopausal symptoms and osteoporosis. Soy isoflavones are one of a group of plant chemicals, best known as phytoestrogens and have impressive abilities which can help to balance estrogen in the body.

Their effectiveness in treating conditions of excess estrogen, such as premestrual syndrome, is derived from the isoflavones’ ability to block receptor sites, whilst in conditions of estrogen deficiency, such as osteoporosis and menopausal symptoms, soy isoflavones can increase estrogen activity by acting as a weak estrogen.

Nonetheless, a new study published by the British Journal of Nutrition suggests the efficacy of soy isoflavones in the treatment and prevention of BPH, a non-cancerous enlargement of the prostate gland. Whilst unpleasant, BPH is a common ailment affecting the prostate of many ageing men which can exhibit various symptoms including trouble starting or maintaining urination, the need to urinate more often, urine leaks or the need to go during the night. Whilst it is thought to be testosterone that is responsible for the changes that cause to prostate to enlarge and put pressure on the urethra, the new study has found that estrogen also plays a key role.

The study into the effects of soy isoflavones on the symptoms of BPH was carried out on men aged 65 and over and found that those with an intake of at least 5 mg of isoflavones, had fewer urinary tract symptoms than those who did not. The researchers suggested that although 5mg is relatively low, it did have a positive effect and emphasises the fact that although low levels of soy isoflavones may be acquired from the diet, a daily natural supplement can significantly help to ensure optimum levels of the beneficial isoflavones to achieve the advantages of reduced BPH symptoms, helping to slow and even prevent prostate cancer growth.