Elizabeth Lucas stories from The Center for Public Integrity

Obama's bundler total exceeds $74 million

2012-02-08T17:45:58-05:00

President Barack Obama’s campaign added 90 new big-money bundlers in the fourth quarter, bringing its army of major backers to 445, according to information released by the campaign Tuesday.

Total funds raised by bundlers — well-connected groups of fundraisers who tap their networks to collect large checks — reached at least $74.4 million.

The newest bundlers accounted for at least $8.2 million. A total of 78 previous bundlers increased the amount they collected.

More than 60 bundlers have now gathered contributions totaling at least $500,000 for the president, a sharp contrast to the campaign’s claims of reliance on small-figure donors. And as with previous bundler disclosures, the list includes a number of individuals who have received appointments and invitations to the White House.

There is no legal requirement for campaigns to disclose the names of their bundlers, and despite cries from good government groups, none of the Republican candidates have shown a willingness to publicly name their star donors.

In 2008, major candidates from both parties released their bundler information. So far this cycle only the Obama campaign has followed that practice.

The campaign discloses its bundlers in four levels: $50,000-100,000; $100,000-200,000; $200,000-500,000 and $500,000 or more. It is impossible to tell exactly how much each bundler raised, but it is possible to arrive at a minimum dollar amount — at least $74.4 million.

At the end of the third quarter, bundlers had raised a minimum of $55 million.

As of Dec. 31, there were 140 bundlers at the $50,000-$100,000 level; 119 at the $100,000-$200,000 range; 125 at the $250,000-$500,000 range and 61 at the $500,000-plus level.

The $74.4 million doesn’t all go to the Obama campaign — it goes to the “Obama Victory Fund,” a joint fundraising committee consisting of the campaign and the Democratic National Committee. It is not known how much of the total went to the campaign and how much went to the DNC.

The maximum contribution to the party is $30,800 per person. The maximum contribution to the campaign is $5,000 - $2,500 for the primary and $2,500 for the general election.

The campaign itself reported raising $39 million in the fourth quarter of 2012, according to Federal Election Commission records.

Records released on Tuesday show that some of the 2008 bundlers who were missing in previous 2012 disclosures signed on again this quarter, among them several people who had previously served in the administration on boards and commissions.

For example, Chicagoan Howard Gottlieb and New Yorker Margot Lion were both appointed by Obama to serve on the President’s Commission on the Arts and Humanities. Both were 2008 bundlers and both have returned for 2012, raising at least $50,000 each. Lion is a New York theater producer.

Obama has taken fire from Republicans for appointing mega donors to administration posts, some largely ceremonial and others advisory. But that criticism has done nothing to keep the administration from giving these donors a role in the White House.

A recent iWatch News report found that at least 68 of 350 Obama bundlers for the 2012 election or their spouses have served in the administration in some capacity; at least 250 of the bundlers visited the White House, and another 30 have ties to companies that conduct business with federal agencies or hope to do so in the future.

At least four of the first-time 2012 Obama bundlers named this quarter have already been appointed to an administration post. Norma Lee Funger, of Potomac, Md., was appointed by Obama on Jan. 18, 2011 to the board of trustees of the John F. Kennedy Center for the Performing Arts.

Glenn S. Gerstell, of Washington, D.C., who has bundled at least $50,000 for the 2012 campaign, was appointed as a member of the National Infrastructure Advisory Commission on Sept. 9, 2011, according to White House records.

Richard Binder, of Bethesda, Md., also has bundled $50,000 or more. Obama appointed him to the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health, May 13, 2011.

On June 8, 2011, Obama announced his intent to appoint Giselle Fernandez to the board of trustees of the John F. Kennedy Center for the Performing Arts. She is a former television journalist.

White House officials have denied that big donors receive special favors and insist that all appointments are based on merit.

Among the donors who stepped up their giving this cycle: Thomas Caranahan, a member of the prominent Missouri political family and the founder of the Lost Creek Wind Farm in DeKalb County, Mo.

Lost Creek was awarded $107 million in stimulus funding in July 2010. Carnahan corralled at least $100,000 for the 2008 campaign and in the third-quarter disclosure was listed at the $200,000 to $500,000 level for the campaign; in the new filing, he is listed at the $500,000-plus level.

Carnahan said in a statement that the project was one of thousands that qualified for grant money and has been generating electricity for “over a year and providing tax revenue, new jobs and other ongoing investments to the community.” He added: “Efforts to link my personal support for President Obama to the success of this project … simply have no basis in fact.”

Many Americans left behind in the quest for cleaner air

2013-04-19T14:36:05-04:00

For all of her 62 years, Lois Dorsey has lived five blocks from a mass of petrochemical plants in Baton Rouge. She worries about the health of people in her life: A 15-year-old granddaughter, recovering from bone cancer. A 59-year-old sister, a nonsmoker, felled by lung cancer. Neighbors with asthma and cancer.

She's complained to the government about powerful odors and occasional, window-rattling explosions — to no avail, she says. Pollution from the plants — including benzene and nickel, both human carcinogens, and hydrochloric acid, a lung irritant — continues.

“If anything," said Dorsey, herself a uterine cancer survivor, "it’s gotten worse."

Americans might expect the government to protect them from unsafe air. That hasn’t happened. Insidious forms of toxic air pollution — deemed so harmful to human health that a Democratic Congress and a Republican president sought to bring emissions under control more than two decades ago — persist in hundreds of communities across the United States, an investigation by the Center for Public Integrity’s iWatch News and NPR shows.

Congress targeted nearly 200 chemicals in 1990 amendments to the Clean Air Act, which the first Bush administration promised would lead to sharp reductions in cancer, birth defects and other serious ailments. But the agencies that were supposed to protect the public instead have left millions of people from California to Maine exposed to known risks — sometimes for years.

Records, some previously undisclosed, show the extent to which Washington is aware of the failure of states and the U.S. Environmental Protection Agency to crack down on localized sources of hazardous airborne chemicals, known as air toxics, even when violations may have continued for years. According to the latest available data, the EPA knows of more than 1,600 “high priority violators” of the Clean Air Act — sites that regulators believe need urgent attention.

About a quarter of these high priority violators appear on an internal EPA “watch list” that includes serious or chronic polluters that have faced no formal enforcement action for nine months or more. Until now, the list has not been made public. The latest version, dated September 2011, shows the names and locations of 383 industrial, commercial, military and municipal facilities, from oil refineries and steel mills to pharmaceutical manufacturers, incinerators and cement kilns. Many of these facilities bombard communities in Texas, Iowa, New York, Arizona, Oklahoma and other states with solvents that can cause cancer, metals that can cause brain damage, or other contaminants.

“There are still places in the country that are overburdened with toxic pollution,” Cynthia Giles, the EPA’s assistant administrator for enforcement and compliance assurance, acknowledged in an interview with iWatch News and NPR.

In Houston, the blue-collar, primarily Latino neighborhood of Manchester lies in the bull’s eye of benzene emissions from the nation’s biggest petrochemical complex. Doctors diagnosed Valentin Marroquin with acute lymphocytic leukemia eight years ago, at age 6. While linking illness to toxic exposure can be difficult, Valentin’s mother, Rosario, doubts he got sick by chance. The ailment has been associated with benzene, and researchers have found elevated rates of childhood leukemia in Houston neighborhoods – including Manchester – with high levels of the chemical in the air. Refineries near Manchester have reported emitting hundreds of thousands of pounds of benzene over the last decade.

“When Valentin was a toddler,” his mother said, “he was running around with all this benzene falling on him.” The teenager, while in remission, lives with worry that his cancer will come back with full fury.

Almost every kind of community is afflicted by air toxics: Middle-class suburbs. Rural patches of the Bible belt. Urban corridors.

In Muscatine, Iowa, pungent haze from a corn processing plant hangs over an otherwise scenic stretch of the Mississippi River. Ash and bits of corn accumulate on houses and cars. For years, state regulators failed to notice what an inspector later characterized as a façade: The factory, while appearing to comply with air pollution rules, exposed nearby residents to a toxic byproduct, state records show. Finally, the EPA raided the plant in late 2009 as part of an ongoing criminal investigation.

In Tonawanda, N.Y., the producer of a key ingredient for iron foundries also violated air pollution rules for years and grossly underreported emissions of benzene and other dangerous compounds into the community, federal documents show. There, too, the EPA eventually stepped in, elbowing aside sluggish state enforcers. A continuing criminal inquiry led to indictments in 2009 alleging violations of the Clean Air Act.

In Hayden, Ariz., the federal government forced a century-old copper smelter to excavate the yards of nearly 300 residents because the soil was contaminated with arsenic and lead. Yet the state still allows discharges into the air of the same metals, which can cause cancer and neurological damage. Some citizens believe generations have been — and will continue to be — poisoned. The state views the smelter as only a minor source of hazardous air pollutants.

In Ponca City, Okla., black mist from a factory that makes a strengthening agent for tires settled on people’s clothes, pets, cars and lawns for decades — and still occasionally falls. Citizen complaints about a lung irritant and possible carcinogen filled 20 binders, but the state environmental agency did little. Emissions declined only after the city and some residents sued the company and won almost $20 million in settlements.

This reality of America’s poisoned places has been eclipsed by the prevailing political narrative. While some business and political leaders, including President Obama, increasingly warn of the impacts of overregulation on the foundering economy, many ordinary Americans face health risks from hazards that could have been limited through better policing.

To be sure, many Americans can breathe easier because of the Clean Air Act. But its intended benefits have eluded many others. As of August nearly 300 of the roughly 1,600 high priority violators had held this dubious distinction for at least a decade, EPA enforcement data show — evidence of a continuing failure by regulatory agencies to keep up.

Within the bureaucracy, the enforcement lapses are hardly a secret. A 2009 report by the EPA’s inspector general found that “in many instances EPA and States are not addressing high priority violations … in a timely manner,” thereby allowing “continued emissions from facilities [that] may result in significant environmental and public health impacts, deterrence efforts being undermined, and unfair economic benefits being created.”

Specifically, the inspector general found that the EPA rarely took over from the states cases involving high priority violators – even though some cases had dragged on for a year and a half or more.

Rep. Henry Waxman, D-Calif., a co-author of the 1990 amendments, said he is troubled by the severe problems that linger in parts of the country.

“I don't think it's a great deal of comfort to tell somebody whose kids may develop brain damage or the adults in the neighborhood who may get cancer that, overall, we’re reducing toxic air pollutants,” Waxman said. “It doesn't help them. What will help them is that the industries that are in their area actually control the pollution and stop poisoning the people.”

EPA acknowledges ‘patchwork of protection’

Two reasons for the government’s inability to muscle habitual polluters into line: Scant resources and politics.

The Clean Air Act delegated enforcement duties to the states, where shrinking budgets have led to less oversight. While the act allowed the federal government to subsidize up to 60 percent of states’ compliance activities, Washington has contributed far less over the past 15 or so years. Today it kicks in only about 25 percent. That translates to a loss of billions of dollars that could have reduced the number of people breathing bad air.

States are getting about $200 million a year in grants from the federal government, said Bill Becker, executive director of the National Association of Clean Air Agencies, which represents more than 200 state, territorial and local pollution control agencies. By Becker’s calculation, the figure should be closer to $700 million. Result: scaled-back enforcement. “We are treading water,” he said.

Michigan could serve as a poster child for the consequences of the budget squeeze. The air division of the state environmental agency has lost about one-fifth of its staff in the past six years, slowing scrutiny of polluters. “Certain things don’t get done as quickly as we would like,” said Vince Hellwig, who heads the division. Annual inspections, for example, aren’t being finished on time.

The EPA, for its part, sometimes is disinclined to wrest policing authority from the states. Eric Schaeffer, a former top enforcement official at the agency, recalls hearing “bitter, bitter complaints” from state officials resentful of planned federal enforcement actions. “It can get pretty tedious,” said Schaeffer, now executive director of the Environmental Integrity Project, a nonprofit group that litigates against polluters.

Politics comes into play, too. In Indiana, Gov. Mitch Daniels, a Republican and former director of the Office of Management and Budget under George W. Bush, has emphasized economic growth. He says the EPA should be renamed the “Employment Prevention Agency.”

Daniels has cultivated relationships with industry leaders, including the CEO of ArcelorMittal, owner of a steel mill near Gary, Ind., that is on the EPA’s watch list.

In 2005, Daniels put a former manager at the mill — when it was owned by Bethlehem Steel — in charge of the Indiana Department of Environmental Management. Under Daniels’s appointee, Thomas Easterly, the department eliminated funding for local air pollution control agencies and made enforcement changes that environmental groups fear could make some cases harder to pursue. The agency said none of the changes threatens public health. “Tom Easterly has been the commissioner for seven years,” Daniels’s office said in a statement. “We do not have concerns.”

In a tough economy, such moves draw less criticism — and, indeed, appeal to Americans wary of a large, unresponsive government. “People here are more worried about surviving day to day and don’t even notice this happening behind their backs,” said Leonard White, a resident of Gary, an industrial city on Lake Michigan beset by six high priority violators within a 15-mile radius.

EPA officials say that while substantial progress has been made under the 1990 Clean Air Act amendments, the results have been uneven. “We’re trying to fill that patchwork of protection that people deserve and expect,” said Gina McCarthy, the EPA’s assistant administrator for air and climate.

It’s not been easy. From the start, the EPA fell behind on issuing air toxics rules for swaths of industries — chemical manufacturers, paint-stripping operations, tire makers. When the rules did come out, they were often branded as weak by environmentalists, who went to court in search of relief. A number of rules were skewered by judges and tossed back to the agency for retooling.

Now, as the EPA tries to address the last major sources of hazardous air pollution — coal-fired power plants, industrial boilers, incinerators and cement plants — it’s encountering headwinds in Congress, mainly in the Republican-dominated House.

The 1990 amendments sought to crack down on sources of 189 chemicals that pour from stacks, leak from pipes and storage tanks and sometimes take the form of “fugitive emissions” from valves and seals. Emissions of the 187 listed chemicals (two were dropped from the original list) fell by 40 percent from 1990 to 2005, according to the EPA.

But this is little consolation to people in communities such as Whiting, Ind. — among the many pockets of enduring pollution where citizens complain that their government has abandoned them. “I gave up on trying to make a difference,” said Paul Myers, who lives within a half-mile of a steel mill and a refinery in Whiting, just east of Chicago, and has spoken out against emissions from the plants. “The spirit of America is alive and well. It’s just not alive and well here.”

Gaming the honor system

The risks to Americans from air toxics may be even greater than EPA records suggest. One reason is a practice of relying on infrequent air monitoring that allows polluters to estimate chemical emissions and submit those estimates to the EPA’s Toxics Release Inventory, a widely used database hailed on its 25th anniversary last month for the way it opens a window for communities on the hazards in their midst. “Everyone has a right to know if danger is lurking in their own backyard,” Sen. Frank Lautenberg, D-N.J., one of the inventory’s prime backers, noted on the anniversary.

The public — and enforcers — may take these self-reported numbers as gospel. They aren’t. Voluntary reporting and the inventory can yield a picture so flawed it dramatically understates the actual amount of pollution. And with poor data, enforcers are hampered from taking meaningful steps.

“What can you do in an enforcement context when the underlying structure of getting the numbers, recording them accurately and reporting them is rotten?” said Schaeffer, who headed the EPA’s Office of Civil Enforcement. “You’re basically building cars without speedometers … and leaving people to guess what the emissions might be.” Studies have documented discrepancies between what’s reported and what’s emitted — sometimes, Schaeffer said, by a factor of 10 or more.

While illegal acts get more attention — and, enforcement officials say, are easier to prosecute — much of the toxic pollution that’s disgorged is legal, sanctioned by the very agencies entrusted to safeguard public health.

Illicit pollution can be the product of poor operations or maintenance. Some polluters save their dirtiest activities for nights and weekends, when regulators aren’t around to respond to complaints. In Muscatine, Iowa, a corn processing plant burned low-sulfur coal when the wind was blowing toward a state-operated monitor. That meant the monitor would detect less of a pollutant, sulfur dioxide, and the plant could avoid added scrutiny, inspection reports and other state records show.

The plant’s owner, Grain Processing Corp., does not dispute switching types of coal when the wind was blowing toward the monitor — but says it acted out of concern for public health. “People assumed that something was being hidden or we were trying to get out of regulation,” said the company's environmental director, Mick Durham, “but that’s not the case at all.”

A sizable amount of pollution requires no chicanery. Under a state-run, federally sanctioned permitting process, substantial toxic emissions sometimes are allowed. Permits don’t always require monitoring or include other protections. In effect, companies obtain licenses to pollute.

Frustration with this system in 2005 prompted two lawyers representing the predominantly African-American town of Mossville, La. — near the petrochemical manufacturing center of Lake Charles — to file an environmental racism complaint with what they felt was the only venue left to them: an international human rights commission. The commission, part of the Organization of American States, accepted the complaint last year — the first of its type to go forward against the United States. The case is pending.

“Every day, Mossville residents breathe toxic chemicals dumped on them by 14 industrial facilities," said one of the lawyers, Monique Harden, who is seeking relocation and medical treatment for her clients. “How is that possible? Well, it’s legal.”

With insufficient resources, regulators across the country have come to depend on an honor system. Companies are expected to volunteer information about their emissions, including when they have exceeded allowable limits. Investigators are finding that cases such as Grain Processing Corp. in Muscatine aren’t unique.

"Attempts to game the honor system are our bread and butter," said Mike Fisher, deputy director of the EPA's office of criminal enforcement, a detective and prosecutorial unit that has some 120 open Clean Air Act cases. Fisher estimates that about 90 of these cases involve efforts by polluters to mislead regulators.

In October, for example, Houston-based Pelican Refining Co. pleaded guilty to felony violations of the Clean Air Act and agreed to pay $12 million in penalties for what the EPA called “numerous unsafe operating conditions” at Pelican’s Lake Charles refinery. Among other things, Pelican admitted in court documents that a monitoring system designed to detect unsafe levels of hydrogen sulfide, a potentially lethal gas, wasn’t working properly, and that it had bypassed a “scrubber” designed to remove the gas from the atmosphere.

‘What am I breathing?’

Some of the chemicals covered by the 1990 Clean Air Act amendments can be seen, smelled or felt. Others are undetectable to the average person. Some accumulate in soil, water and food.

A few of the compounds are familiar (asbestos, lead) but many are obscure, with unpronounceable names like 2,3,7,8-Tetrachlorodibenzo-p-dioxin. All are destructive. Congress specified them in the amendments because they can cause cancer, birth defects, brain impairment, respiratory disease or other serious maladies; many of these conditions don’t appear until years or decades after exposure and aren’t easily tied to a particular chemical or family of chemicals.

When it comes to environmental health, precise cause-and-effect can be hard to determine. But the anxiety stirred by toxic chemicals, especially among parents, is considerable — in some cases worse than the physiological damage they inflict. “It’s awful,” said Tonya Pilch, one of several residents of Fernandina Beach, Fla., who complain about emissions from a pulp mill. “I don’t know what it lets off, but you can taste it. There’s a mist you can see in the air when it’s really bad. I wonder, what am I breathing?”

Under the Clean Air Act, the EPA sets limits for soot and a few ubiquitous pollutants, such as sulfur dioxide. If higher levels are detected, stricter pollution controls may be required.

For a city like Gary, this means that steel mills, power plants and an oil refinery in the area must hold down emissions of fine particles that can cause respiratory problems and chemicals that can form smog. But there are no comparable restrictions on most air toxics, like manganese, which can affect the nervous system.

The EPA has set compound-specific standards for only seven of the hundreds of air toxics: asbestos, benzene, beryllium, inorganic arsenic, mercury, radionuclides and vinyl chloride.

The others? Covered by the sorts of broad, sector-wide rules that have been criticized by the courts.

In Gary, the dark haze from steel mills and power plants that once hovered over the community has lessened. Still, some worry about the unseen. “It could be a clear day, and it’s toxic as hell,” said Lin Kaatz Chary, a former steel mill worker and now a public health advocate. According to 2005 EPA data — the most recent available — people living in some neighborhoods in the Gary area were among the 5 percent of Americans facing the highest risks of cancer from hazardous air pollutants.

While tangible effects of emissions can be hard to measure, shards of circumstantial evidence sometimes emerge. In December, for instance, a study by the Texas Department of State Health Services concluded that the prevalence of birth defects in a three-county area that includes Corpus Christi — home to several large oil refineries, one convicted of criminal Clean Air Act violations in 2007 — was 74 percent higher than the rest of the state.

A 2010 study by researchers at the University of Texas School of Public Health found that women living in Houston-area census tracts with the highest benzene levels were more than twice as likely to have children with spina bifida than women living in areas with lower levels. And a 2008 study by researchers with the same institution found that benzene-saturated census tracts in the Houston area had elevated rates of childhood leukemia.

Such studies don’t prove that toxic emissions are harming children in Corpus Christi and Houston. But the law says that such proof isn’t required. Congress told the EPA to zero in on 189 chemicals — by and large, the worst of the worst — because of their well-documented ability to sicken and kill people.

Broken promises and the ‘watch list’

President George H.W. Bush couldn’t have made the goal any clearer when he signed the Clean Air Act amendments into law in November 1990, declaring “my determination that each and every American shall breathe clean air.” His EPA administrator, William K. Reilly, predicted that “30 million tons of toxic chemicals will be prevented from fouling the air every year” and that “as a result, air toxics risk will be slashed by three-quarters, and health problems will be reduced significantly, including cancer risk, respiratory disease, heart ailments and reproductive disorders.”

But the law’s promise remains unfulfilled. iWatch News and NPR sought to determine the scope of the air toxics threat by analyzing federal and state data, reviewing documents and doing ground-level reporting in 10 states. One of the documents was the Clean Air Act enforcement watch list, which as of September included 383 facilities. iWatch News and NPR obtained it by filing a Freedom of Information Act request. The news organizations earlier had obtained the July version of the list, which included 416 facilities.

According to a 2008 EPA report, the watch list reflects “recidivist and chronically noncomplying facilities whose violations have not been formally addressed by either the state or EPA.”A 2009 report by the EPA’s inspector general put it similarly: The list tracks “facilities with serious or chronic violations of environmental laws but with no formal enforcement response.” EPA officials said facilities on the list have not been subject to enforcement actions for at least 270 days following the discovery of a violation — a delay of nine months.

Most facilities on the list, which is updated monthly, are classified as high priority violators. Among the criteria for becoming a high priority violator: Excessive emissions of air toxics; violation of a state or federal order; and monitoring or recordkeeping deficiencies that “substantially interfere with enforcement.”

Not every high priority violator has been formally found to have broken rules. A plant can be considered a high priority violator even if its owner has reached a court settlement with the EPA, which wants to make sure all terms of the agreement are met. “You come off the [high priority violator] list when all the actions under the settlement have been completed,” said a senior EPA enforcement official, who asked not to be identified because he is not authorized to speak for the agency. “It takes time for the [required] work to be completed. We don’t trust these companies fully and want to maintain federal court supervision.”

Reporters with iWatch News and NPR attempted to contact representatives of all facilities on the July and September versions of the watch list. Most didn’t reply or declined to comment. Some of those who did respond seemed puzzled by their plants’ inclusion. Bill Day, a spokesman for Valero Energy Corp., which had seven sites on the September list, wrote in an email that the company’s facilities “operate under permits, and we work with federal, state and local regulators to ensure compliance with those permits. All issues are remedied as quickly as possible.”

Charles Drevna, president of the National Petrochemical & Refiners Association, wrote in an emailed statement, “In the short time we have had to examine the list of fuel and petrochemical manufacturing facilities on the EPA Watch List, we and our members have found multiple instances of outdated and inaccurate information, along with failures to note that reported violations have already been resolved.”

Officials in some states also cautioned against reading too much into the EPA data. “Just because [companies are] on the list doesn’t mean we’re not actively working on them and pursuing a remedy to the concern,” said Brad Frost, a spokesman for the Illinois Environmental Protection Agency. Illinois had 37 facilities on the list as of September; only Ohio and Texas had more.

Not every facility on the list may be a serious or chronic offender. While the EPA’s own documents describe the list that way, agency spokesman Larry Jackson said in an email that facilities may appear on the list for other reasons. For instance, enforcement officials may be tracking a polluter’s compliance with a court order. A company in negotiations with authorities also might be on the list. In other instances, violations may have been alleged but not proven. There also may be data errors — for example, a state agency’s failure to report an enforcement action to the EPA.

Jackson emphasized that the watch list “does not identify which violations may pose the greatest risk to public health or the environment.”

Even so, the analysis of EPA enforcement records by iWatch News shows that 95 percent of the facilities on the September list were classified as high priority violators.

The reason each facility is on the list — spelled out on the EPA’s internal version — is closely guarded by the agency. The EPA declined to disclose these details to iWatch News and NPR, citing a Freedom of Information Act exemption protecting law enforcement techniques and procedures.

Grant Nakayama, EPA enforcement chief under George W. Bush, said the list has been kept secret in part because of "violators out there that are really interested in gaming the system, beating the system, and anything that gives them forewarning, I think, would not be helpful."

While air toxics are concentrated in certain industries — such as oil refining, steel manufacturing, and coal-fired power generation — the watch list includes a broad cross-section of companies. Six industries account for more than one-third of the facilities: oil refining; electric power generation and distribution; organic chemical manufacturing; steel manufacturing; solid waste disposal; and crude oil and natural gas extraction.

More than half of the facilities on the September list are located in six states: Ohio, Texas, Illinois, Louisiana, Wisconsin and Indiana. About two-thirds are large enough to report to the Toxics Release Inventory; collectively, they admitted putting out some 34 million pounds of hazardous air pollutants in 2009.

Among them is the Huntsman Corp.’s chemical plant in Port Neches, Texas, owned by the family of Republican presidential candidate and former Utah governor and U.S. ambassador to China Jon Huntsman. Data reported by the company to the EPA show that the plant discharged nearly 300,000 pounds of chemicals into the air in 2009, including 142,000 pounds of substances on the hazardous air pollutant list. It’s recorded 27 separate high priority violations since February 2002, EPA data show. Neither Texas nor company officials responded to requests for comment.

EPA ‘still playing catch-up’

Many more polluters generate prodigious quantities of air toxics than are on the EPA watch list. All told, in 2009 the roughly 13,600 facilities required to report to the Toxics Release Inventory said they emitted at least 600 million pounds of hazardous air pollutants.

Some communities are in the crosshairs of multiple sources of pollution. Eight plants in Channahon, Ill. — a middle-class town of 12,500 about 50 miles southwest of Chicago — reported releasing some 644,000 pounds of air pollutants, including 163,000 pounds of toxics, in 2009.

Tammy Thompson, who lived in Channahon from 1998 to 2008, said the air got “progressively worse” beginning around 2002. “The fumes would come into your home,” she said. “My husband and daughter and I would wake up coughing and gagging in the middle of the night.”

Thompson said she complained repeatedly to the Illinois Environmental Protection Agency but saw no improvement. Prompted by an inquiry from then-Sen. Barack Obama, an official with the U.S. EPA in Chicago explained in a 2007 letter to Thompson that the state had “primary responsibility” for enforcing the Clean Air Act and that regional monitoring showed that “air quality in the area where you live is generally good.”

Convinced that neither the state nor the federal government was going to protect them, Thompson and her family left Channahon three years ago and now live 20 miles away. “We took a $40,000-plus hit on our home just to get the heck out of there,” Thompson said.

A spokeswoman for the Illinois Environmental Protection Agency, in an emailed statement, wrote that the agency takes citizen complaints seriously and has inspected “all potential Channahon odor sources.” Two refineries that have been targets of residents’ ire are operating within the limits of their air permits, the spokeswoman said.

EPA officials generally tout their progress in cutting emissions nationwide — not the communities left behind. Giles, the EPA’s assistant administrator for enforcement, said the agency’s actions are “removing millions of tons of pollution from the air and water every year.” In the past 12 years, spokesman Jackson said, the EPA has reached court settlements with — or taken administrative actions against — 106 refineries; 242 units at 75 power plants; and 88 ethanol plants, among other polluters. Over a 20-year period beginning in 1989, the agency opened more than 1,600 criminal Clean Air Act cases, Jackson said.

But McCarthy, the EPA’s assistant administrator for air, acknowledged that “we’re still playing catch up” with the requirements of the Clean Air Act amendments.

EPA administrator Lisa Jackson declined multiple requests to be interviewed for this story.

Citizens fight back: ‘Bucket tests’ and lawsuits

With government unwilling or unable to pursue polluters with more zeal, citizens in some of the hardest-hit communities have taken matters into their own hands, collecting air samples at factory fence lines and hiring lawyers to pursue intractable polluters in court.

In Tonawanda, N.Y., a suburb of Buffalo, residents fed up with chemical emissions from a plant owned by Tonawanda Coke Corp. began taking air samples outside the plant using specially equipped buckets. The sampling put federal investigators on the path to finding that the plant’s benzene output was 30 times higher than what it had reported to the EPA, agency documents show.

“It burns your eyes. It burns your throat. It’s just bad,” said Jeani Thomson, who has lived near the plant for 30 years and has had an array of illnesses. “I have everything under the sun that can possibly be wrong with a person and still be walking around. I have eye issues … I have had three different cancers. I have one lung. Half a stomach.”

In Ponca City, Okla., homes were invaded by fine, black dust from the Continental Carbon plant until the city and residents, including members of the Ponca Tribe, filed a string of lawsuits that brought multi-million dollar settlements and prompted state regulators to rewrite their rules. The company blamed other sources for the pollution, but declined to release its test results to iWatch News and NPR.

“Living with that plant was a complete nightmare,” said tribe member Karen Howe. “The dust came into your home. … I tried to get the kids a couple of pets — of course, they were outside dogs. As soon as they were outside even three or four days you couldn’t even pet them because your hands would be all black. If they rubbed up against you it would be black on your skin and on your clothes.”

In the late 1990s, several hundred residents of Hayden, Ariz., sued Asarco, owner of one of the nation’s few remaining copper smelters, hoping to get enough money to move away from the arsenic- and lead-contaminated town east of Phoenix. The company entered bankruptcy some years later and avoided big payouts. People are stuck, and the pollution continues.

Mary Corona, 53, has lived in Hayden since birth and said she suffers from constant, throbbing pain, as well as frequent bouts of nausea, dizziness and memory loss. She takes 10 prescription medications, including the powerful painkiller Oxycontin. When she was about 5, she began getting welts on her torso that looked like cigarette burns, she said. She remembers seeing thick clouds of dust from the Asarco tailings pile — today, a literal mountain of mining waste. Some neighbors have cancer; others have died. “There were people who could have stopped this years ago,” Corona said. “They didn’t care.”

Now and then, a court case against a polluter confirms the kind of corporate behavior citizens fear.

In July, a jury in St. Louis awarded $358.5 million — including $320 million in punitive damages — to 16 former residents of Herculaneum, Mo., who were poisoned as young children by airborne lead from a Doe Run Co. smelter. Evidence at trial included a confidential 1989 memo recommending against a mass buyout of contaminated houses.

“Implementation of such an idea would almost certainly invite a major class action suit,” a consultant wrote to one of the smelter’s three owners at the time. The owners decided to stick with the plan already in effect: Buy a few houses a year and rent them out with the stipulation that no children be allowed to live in them. Children, the consultant noted in his memo, are “more vulnerable than adults” to lead’s brain-altering effects.

In Baton Rouge, where Lois Dorsey has long worried about the health of her family and friends, EPA numbers seem to confirm suspicions of dirtier air. Emissions of hazardous air pollutants from five petrochemical plants clustered near Dorsey’s home jumped 14 percent in 2010 compared to the average for the previous five years, according to iWatch News’ analysis of Toxics Release Inventory data reported by plant owners.

An organization known as the Louisiana Bucket Brigade, has taught residents of Baton Rouge and other communities how to take air samples, shoot video and otherwise document air pollution problems. The bucket brigade’s program manager, Anna Hrybyk, isn’t surprised by the apparent rise in pollution. The response by state regulators to citizen complaints tends to be “very sluggish, often to the detriment of public health,” Hrybyk said.

Dorsey and her neighbors live in a state of disquiet. “I wonder about my health,” Dorsey said. “I’m 62. Am I going to live to 70, or even 66?”

Upstate of Baton Rouge, in Shreveport, members of Residents for Air Neutralization, a grassroots group in a predominantly African-American neighborhood, donned T-shirts saying “Clean Air Is Our Right” and went out with buckets on a sticky July 4 weekend in search of noxious odors from the Calumet Specialty Products oil refinery, about which they have complained for a decade.

Over community objections, the Louisiana Department of Environmental Quality (LDEQ) approved a refinery expansion in 2006. Then, last December, Calumet agreed to pay a fine of $1 million for air emissions from its three plants in Louisiana, including in Shreveport, and to spend up to $15 million more on long-term pollution-control projects.

In one sense, the action confirmed what residents have said for years: The Shreveport refinery was polluting the air. But the settlement did little in real terms, residents say. The state refuses to back their main wish — to be relocated. Under the pact, moreover, it agreed not to punish Calumet if old violations were later uncovered. State officials said the clause was justified in the context of a settlement intended to produce cleaner air. Louisiana has long believed industry’s economic and job-creating benefits “greatly outweigh” the costs of pollution.

“I always thought LDEQ and EPA were supposed to be for the people. EPA stands for Environmental Protection Agency,” said Velma White, leader of Residents for Air Neutralization, stressing the words for impact. Her group, she said, “wouldn’t have been organized if LDEQ and the EPA were for the people.”

In public forums, Calumet has pitched itself as a job provider that tries "every day" to limit odors and emissions. In a filing with the Securities and Exchange Commission, the company — which did not respond to interview requests — said it did not expect the fine or the state-ordered improvements to have a “material adverse effect on our financial results or operations.”

The multimillion-dollar package was merely the price of doing business.

This article was reported by Jim Morris, Chris Hamby and Elizabeth Lucas, and written by Morris.

Ronnie Greene and Elizabeth Shogren contributed to this story

Methodology

2011-11-07T05:06:01-05:00

The Poisoned Places series relied on analysis of four datasets relating to sources of air pollution regulated by the U.S. Environmental Protection Agency: the Clean Air Act watch list, the Air Facility System (AFS), the Toxics Release Inventory (TRI) and the Risk Screening Environmental Indicators model (RSEI).

The Clean Air Act watch list

The Center for Public Integrity’s iWatch News and NPR obtained the “watch list” through a Freedom of Information Act request to the EPA. Two versions of the list were obtained: one current as of July 2011, the other as of September 2011.

While these facilities are regulated by the states and the EPA, not all facilities report to the EPA’s Toxics Release Inventory (TRI); certain criteria must be met.

Further research indicated that two of these facilities are under construction, two are temporarily closed and nine are permanently closed. Additionally, not all were flagged in the data as high priority violators (HPVs) as of August 2011. iWatch News and NPR placed watch list facilities into industry categories and used the primary four-digit Standard Industrial Code; data entry for the more current North American Industry Code System was not as consistent.

The Air Facility System

AFS tracks permit, enforcement and compliance information for sources of air pollution. All major sources and some minor sources are required under the Clean Air Act to obtain operating permits that stipulate what they must do to control air pollution. The data contain information about inspections, enforcement actions, penalties and compliance, including HPV status. The HPV flag is activated when a facility has a high priority violation, as defined by criteria established in a 1998 EPA memo. It is deactivated when the violation is fully resolved. In some cases an HPV flag can remain after a violation has been resolved.

State or local agencies are required to report data to the EPA on a regular basis. However, because of some technical complications or lack of diligence, data are not always entered in a timely manner. Therefore the data do not always present a complete picture of enforcement or compliance for a particular facility. States’ comments on data inaccuracies can be found on the EPA’s website.

iWatch News and NPR downloaded AFS data from the EPA Web site in October, and the data are current as of August 2011. To compensate for incomplete data, iWatch News and NPR contacted multiple state and local agencies, EPA regional offices and the national office in Washington, D.C., to try to corroborate information gleaned from AFS.

iWatch News also obtained a detailed subset of the AFS database through the Freedom of Information Act. It details the steps regulators have taken to address concerns involving what the agency considers "high priority violators" across the country.

The Toxics Release Inventory

The TRI, authorized under the Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA), houses emissions data reported yearly by polluting facilities. More than 20,000 facilities reported emissions of some 600 chemicals in 2009, including most of the 187 hazardous air pollutants that the EPA is required to control, as defined in the 1990 amendments to the Clean Air Act.

Not all toxic chemicals or sources of pollution are included in the TRI, however. Smaller sources (such as dry cleaners and gas stations) and mobile sources are not required to report. Only facilities in certain industry sectors, with a minimum level of production and number of employees, must report each year.

In addition, some quantities reported are estimated rather than monitored, and facilities use different estimation methodologies that could result in slightly different amounts. It is widely acknowledged that the TRI also contains some reporting errors, and in some instances facilities underreport.

The EPA also notes that no health risk conclusions can be drawn from the TRI alone, since there is no information on toxicity or distribution of chemicals.

iWatch News and NPR analyzed the most recent complete version of data through 2009. Only fugitive and stack (on-site) air releases were considered when analyzing emissions. Completed 2010 reports became available from the EPA 11 days before publication — after iWatch News and NPR finished their analysis. iWatch News and NPR plan to use the 2010 data as the series continues.

The Risk Screening Environmental Indicators

RSEI was created by the EPA to assess chronic human health risks from chemical releases reported in the TRI. For each release, the model takes into account the toxicity of the chemical, its fate and transport through the environment, the exposure pathway (air or water) and the number of people potentially affected. The model produces a relative risk score for each release. The latest version of the model (version 2.3.0) is based on the 2007 version of the TRI.

The screening model does not produce a measurement of actual risk, nor does it address acute (or immediate) risk from toxic air releases. It produces relative results for comparison, and its primary use is for identifying chemicals, industries or localities that require further investigation.

The model makes some necessary assumptions that should be considered when looking at its risk scores. Chemicals are assigned toxicity weights, but in some cases where chemicals are grouped together, the entire group is assigned the toxicity of its most toxic member. Also, if some facility information (such as stack height) is unavailable, the model will plug in alternate information (such as the national median stack height).

Since the model is based on TRI reports, it is subject to the same caveats. If a facility reported incorrectly in 2007 and later amended the report, the incorrect quantity will be reflected in the RSEI score, which was calculated using the 2007 version of the TRI.

For the interactive map, iWatch News and NPR used the latest version of RSEI to place facilities in one of five risk categories. Before doing this, several RSEI experts were consulted, both inside and outside of the EPA. To place the facilities in a risk category, iWatch News and NPR first averaged the risk screening scores associated with the facilities over the five-year period, from 2003 to 2007 (the latest year of data available).

Because the initial analysis revealed the distribution of those averages to be skewed, iWatch News and NPR applied a Log10 data transformation to place the data in a normal distribution. Once transformed, the data were grouped into five categories based on the transformed quantities, from lowest to highest.

Forty percent of Medicare spending on common cancer screenings unnecessary, probe suggests

2012-07-17T12:12:35-04:00

Terry Waddell knew that her 87-year-old mother did not have long to live. The woman’s organs were shutting down because of old age, she said, and her arthritic body had withered to 80 pounds.

So, when Waddell received a call about her mother’s health, it was not what she expected. A visiting nurse had noticed a bit of blood between the frail woman’s legs and wanted her screened for cervical cancer.

Waddell, of Houston, regrets that she took her mother for the test. She refused to let doctor’s aides weigh her, she said, protesting that getting her mother out of her wheelchair was too arduous a process. Then came the actual exam, which she said “was painful to watch.” Her mother struggled to open her legs wide enough for the procedure and then lay there, quietly crying.

“I blame myself for not stopping this,” said Waddell, whose mother died two months later.“It was totally unnecessary.” Unnecessary, perhaps, but surprisingly common.

Cancer screening tests are vastly overused in the United States, with about 40 percent of Medicare spending on common preventive screenings regarded as medically unnecessary, an iWatch News investigation reveals. Millions of Americans get such tests more frequently than medically recommended or at times when they cannot gain any proven medical benefit, extracting an enormous financial toll on the nation’s health care system. Doctors disregard scientific guidelines out of ignorance, fear of malpractice suits or for financial gain, as patients inundated by medical advertising clamor for extra tests.

In the frenzied hunt for cancer, the risks of the screenings also get overlooked. Besides producing anxiety, screening people for cancer can itself cause injuries — even death — or set off a cascade of expensive tests and treatments that can waste more money and create more problems.

The U.S. Preventive Services Task Force, a panel of independent medical experts, determines which screening tests offer more benefits than risks — and who should get them. But even though the group’s guidelines are considered the gold standard for medical care, its detailed recommendations are largely ignored, an iWatch News’ probe found, and the fiscal consequences are profound.

Medicare spent about $1.9 billion on common cancer screenings for people who were older than government-recommended age limits between 2003 and 2008, according to iWatch News’ examination of a six-year sample of Medicare billing records obtained by iWatch News and The Wall Street Journal. That’s about 40 percent of everything that Medicare spent on breast, colon, prostate and cervical cancer screenings in that time period.

More than $31 million of that money was spent screening people who were in their 90s, the investigation showed.

Breast cancer screening guidelines were disregarded most frequently during this period, according to the iWatch News analysis. More than 22 million mammogram claims were submitted for women at or over the recommended limit of 75, the age when the task force says “evidence of benefits of mammography is lacking.” (The number of claims cited for each test is greater than the number of procedures as hospitals and doctors both sometimes bill separately for each procedure. See methodology for more details.) Health care providers, meanwhile, billed Medicare for more than 10 million colon cancer screening claims and more than 6 million prostate cancer screening claims for people at or over the suggested upper age limit of 75.The task force gave these prostate screenings its strongest negative rating, actually discouraging their use.

For cervical cancer screenings, which the government panel says can usually stop at 65, over 80 percent of Medicare claims — more than 13 million — were for women who were 65 or older.

“This is a very bad way to expend money that is in short supply,” says Dr. Virginia Moyer, chair of the Preventive Services Task Force, noting how harmful these tests can be. “There’s human suffering involved.”

Adds Clyde Behney, the Institute of Medicine’s deputy executive officer: “It’s a very sad testament to the system’s workings.” The Institute, part of the National Academy of Sciences, advises the government on health issues.

The government is sending mixed signals, medical experts say, with one agency discouraging older patients from getting preventive screening tests and another one paying for them — and implicitly endorsing their use. All the while, the tests get promoted by corporations that have a financial interest in them being administered. Even some diaper companies get involved, experts say, noting that they can financially benefit from men getting medically questionable prostate tests and then winding up incontinent.

The $1.9 billion spent on excessive testing, meanwhile, represents only a fraction of how much these screenings actually cost the health care system, asserts Dr. H. Gilbert Welch, a Dartmouth medical professor, who says the most expensive part of screening involves the extensive battery of follow-up exams and procedures, such as biopsies.

“The test is chump change. It’s all the stuff that happens afterward that costs a lot,” says Welch, author of Overdiagnosed: Making People Sick in Pursuit of Health.

Welch calls overdiagnosis, the process of detecting medical abnormalities that will never harm patients’ health, “the biggest problem posed by modern medicine.”

iWatch News’ findings come in the midst of an intense national debate over the future of Medicare, the financially strapped health care program for seniors and the disabled. Republicans ignited a political firestorm earlier this year, proposing a radical overhaul of the entitlement program that would give seniors vouchers to buy private health insurance. Democrats condemned the plan and insisted that President Obama’s landmark health care reform could control Medicare’s rapidly escalating costs. Medicare costs are now being examined anew by the so-called Super Congress searching for long-term spending cuts.

If unnecessary screenings were cut, health care could actually be improved, says Dr. Mark Stoler, a medical professor at the University of Virginia. “We’re brainwashed in America to think that more is better,” he says.

But the “more is better” mindset is difficult to budge — especially where Medicare is involved.

Every time Medicare tries to rein in spending, “the great R word comes out,” says Gail Wilensky, a former director of the Medicare program, referring to health care rationing.

Any suggestion of an upper age limit on preventive cancer screening would likely be greeted with howls of age discrimination, medical experts say. Congress has often overruled Medicare administrative decisions designed to reduce costs.

“There will always be a political advocate or medical manufacturer who can point to a life being saved by screening, no matter how much it makes no sense from an epidemiologic perspective,” says Dr. Peter Albertsen, a urologist and associate dean at the University of Connecticut Health Center. “This is too politically sensitive. No one wants to see someone develop cancer.”

Despite repeated requests, the Centers for Medicare and Medicaid Services refused to comment on iWatch News’ findings or on the broader question of whether CMS has ever considered curbing preventive screenings for the elderly. A CMS spokesman would say only that “decisions on who gets these screenings and whether to administer them are between patients and their doctors.”

For Medicare administrators, says Wilensky, “there’s real reluctance to interfere with the doctor-patient relationship.

Screening on autopilot

Medicare should at least consider refusing to pay for preventive screenings for the terminally ill, say researchers, who recently discovered that a significant number of patients with advanced cancer were still undergoing preventive tests.. “Even when the benefits have been rendered futile,” 15 percent of terminally ill men received prostate cancer screenings, while 9 percent of terminally ill women got mammograms and 6 percent got Pap smears, according to a study published last year in the Journal of the American Medical Association.

Doctors are often reluctant to tell sickly or elderly patients that they can’t possibly live long enough to benefit from cancer screening tests, says Dr. James Goodwin, a geriatrician at the University of Texas Medical Branch. Sometimes, he says, he’ll order unnecessary tests for insistent patients, thinking it’s most important to maintain people’s trust for future medical treatments. “Medicine is a social interaction,” he says.

At American medical schools, meanwhile, the importance of preventive screening gets drilled into doctors. After learning to make every effort to find potential health problems, it’s difficult for them to follow updated guidelines that say less screening is better.

“It is very hard to get out of these habits,” says Dr. Howard Brody, director of the University of Texas’ Institute for the Medical Humanities. “It feels like going without clothes on.”

Financial considerations, of course, play a huge role, too. Screening can generate enormous profits — especially for physicians who own testing or treatment equipment. Studies show that doctors who own such equipment typically do two to three times more procedures than their counterparts, Dr. Brody says.

Medicare’s fee-for-service structure also fosters more tests, since doctors get paid by the exam. The threat of medical malpractice lawsuits is never far away, either, discouraging doctors from trying too hard from talking patients out of tests. “No one ever gets sued for overscreening,” Goodwin says.

With so many economic and cultural pressures, the latest and most comprehensive medical research can get completely ignored.

“We have guidelines and scientific articles, but they have no teeth,” Dr. Stoler adds. “We have chaos.”

The U.S. Preventive Services Task Force guidelines were never meant to be mandates, and only recently gained a bit of regulatory heft. Under President Obama’s health care plan, its ratings are used to determine whether patients need to make co-pays for preventive screenings. Patients no longer need to pay anything for preventive tests that the task force recommends: those receiving either the task force’s “A” or “strongly recommended” rating or its “B” or “recommended” rating. In addition, beginning in 2009, the Secretary of Health and Human Services received administrative authority to expand Medicare’s preventive services, if a service gets an A or B rating from the task force.

Still, the panel’s upper age limits on screenings are primarily designed to help health care providers weigh the risks and benefits of each test.

“The issue of when you stop screening is an extremely difficult one,” says Moyer, the task force chair. While slow-growing cancers won’t cause serious symptoms for at least a decade, some tests can cause incontinence, bowel perforations, and even death.

There’s no point in screening for slow-growing cancers in people who will likely die in the next decade of something else, she says. “People all think they’re the exception.”

Concerns over prostate tests

Prostate cancer screenings and follow-up exams have so many risks and such dubious benefits that the task force does not recommend anyone take the tests. For men 75 or older, the tests received the panel’s lowest rating: a D, meaning “discourage the use of this service." The preventive services panel is expected next week to propose the same D rating for tests given to younger men, according to CNN. Currently, for men under 75, the tests get an I rating, which means there is insufficient evidence to determine that the test’s benefits outweigh its risks.

Yet Medicare spent more than $149 million on prostate screening tests for these older men between 2003 and 2008, iWatch News found. That’s 36 percent of all Medicare spending for such tests during this period.

More than $4 million of this money was spent on testing men in their 90s — even though prostate cancer usually grows quite slowly.

The decision to have Medicare pay for these controversial tests did not come from Medicare administrators; instead it was mandated in 1997 by Congress, which ignored the advice of its own research experts.

When Congress asked the Office of Technology Assessment, its now-defunct research agency, about whether the government should pay for the prostate tests, the agency cautioned: “An unrestricted, permanent benefit might imply that science actually has established the benefit of early detection.” At that time, the governments of England, Sweden, Australia and the Netherlands opposed routine screening for all ages, as did the U.S. and Canadian preventive services task forces.

Medical societies in the United States, meanwhile, were divided on the tests’ effectiveness, with some touting them as “some sort of screening marvel” and other denouncing them, said Behney, then one of the Office of Technology Assessment’s assistant directors. The problem was that the tests were notoriously inaccurate and could lead to unnecessary treatments with devastating side effects, such as incontinence and impotence.

But the legislation had some powerful backers. Sen. Richard Shelby, R-Ala., had sponsored the 1995 version of the legislation, which was cosponsored by the late Sen. Ted Stevens, an Alaska Republican. Both men were prostate cancer survivors.

After Congress authorized Medicare to pay for the tests, experts continued their warnings. Dr. Harold Sox, then president-elect of the American College of Physicians, testified at a congressional hearing that Medicare’s directors needed to “strongly caution physicians to avoid routine screening.” It was hard to get the message heard, with prominent politicians and athletes testifying that the screening tests had saved their lives.

Now, though, an increasing number of scientists question the usefulness of the PSA test, the common blood test used to detect prostate cancer. Several recent studies have shown that the screenings do not lower the cancer’s death rate.

The test’s accuracy remains an issue. The blood test detects high levels of an enzyme called prostate-specific antigen, but that enzyme can be elevated for lots of reasons — not just because of prostate cancer. Even Dr. Richard Ablin, who discovered the antigen, has called the test “hardly more effective than a coin toss.”

“The manufacturers of the PSA test sold the urological community on a test that cannot detect what it purports to detect,” Dr. Ablin proclaims on his website. The PSA blood test alone may not be harmful, but serious risks — and hefty expenses — occur with what often follows: biopsies, radiation therapy, and possibly surgery.

Making matters even more complex: confusion over which prostate cancers are dangerous. Some cancers grow so slowly that they will never affect a man’s health, yet it’s hard to tell which ones are more aggressive.

So, if someone gets diagnosed with prostate cancer, figuring out whether to treat them is not an easy decision. About 30 to 40 percent of men who undergo prostate cancer treatment become impotent, while 20 to 30 percent become incontinent, experts say.

“Screening is about fifty times more likely to ruin your life than it is to save your life,” says Dr. Otis Brawley, chief medical officer of the American Cancer Society, citing the results of one key study.

Yet prostate cancer screening remains a huge industry in the United States. Hospitals can generate enormous profits from them and sometimes offer free screenings to recruit new patients. By offering free tests to just 1,000 patients, a hospital can bill Medicare and insurance companies $4.9 million in follow-up procedures, Brawley said — a figure calculated by previous administrators at an Atlanta hospital where he once worked.

HealthFair, which takes screening vans to corporations and community events, used to advertise its services to hospitals on the Internet, saying: “With patient revenue being down as much as 30 percent in some specialty physician groups, a partnership ... can bring tremendous value to you.”

Zero, the Project to End Prostate Cancer, meanwhile, now takes its vans to 60 locations around the country each year, offering free PSA tests — a practice that Brawley believes is unethical. Mass screening programs, he says, “actually deceive men into thinking that screening is better than the science tells us.” Jamie Bearse, Zero’s chief operating officer, said every man receives information about early detection, adding “the American Cancer Society condemns some men to death with its stance on PSA testing today.”

Even Kimberly-Clark, the maker of Depends adult diapers, has launched campaigns to end prostate cancer, donating money to Zero.

Says Brawley: “While it is a question as to whether prostate screening saves lives, it definitely sells diapers.” A Kimberly-Clark spokesman said its campaign’s intent was not to sell diapers. The campaign’s goal was “bringing an end to this terrible disease,” according to a company press release.

Medicare reimburses health care providers large sums for some prostate cancer treatments, paying as much as $40,000 a patient for intensity-modulated radiation therapy. The government insurance program spent an estimated $1 billion in 2008 on this therapy, according to an analysis of Medicare records by The Wall Street Journal.

“I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster,” Dr. Ablin wrote in a New York Times op-ed column last year. Eliminating routine PSA screening, he said, “would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.”

Leading manufacturers of prostate cancer screening tests did not respond to requests for comment.

A glut of colon cancer screenings

Unlike prostate cancer screenings, colon cancer tests are not controversial at all. With colonoscopies, polyps can be detected and removed long before they become cancerous.

But as people age, colonoscopy risks increase and the benefits of the tests decline.

People over 80, for instance, are 75 percent more likely to experience severe side effects from the procedure, such as bowel perforations, compared to people in their late 60s, a recent study showed. Yet they may not get any benefits from the tests for more than a decade, since it can take that long for polyps to become cancerous.

Given the shifts in risks and benefits, the U.S. Preventive Services Task Force does not recommend routine colon cancer screening for people over 75.

The net benefits of screening are small for people between 76 and 85, the panel says. For those over 85, it says, the benefits do not outweigh the harms.

Yet iWatch News found that Medicare spent more than $323 million doing colon cancer screenings for people 75 and older between 2003 and 2008. That’s more than 30 percent of what Medicare spent on these tests during that time period.

More than $34 million of this money was spent screening people 85 and older.

One of nearly every four Medicare recipients, meanwhile, gets expensive colonoscopy tests too frequently, a recent study showed. Instead of getting the routine screenings once a decade, as recommended, these people were taking the tests every seven years, says Dr. Goodwin, who led the research project.

Public health campaigns urging people to get regular screenings are considered a great success, but “the lessons got overlearned,” Goodwin said.

People were more likely to be screened too frequently if they got their tests done in an office or by doctors who did a large number of procedures, Goodwin found. The providers usually billed these extra tests as diagnostic, meaning they claimed the patients showed some sort of cancer symptoms. But when Goodwin investigated the actual claims, he said, “a lot of the indications were real bogus.”

Medicare reimburses hospitals an average of almost $800 per test.

Not all doctors believe testing over the age limits is excessive.

At the Banner Arizona Medical Clinic in Peoria, Ariz., many colon cancer screenings were performed on patients 85 or older, the iWatch News analysis showed. But this clinic serves patients from nearby Sun City, Ariz., the nation’s first planned community for active seniors. Some patients are 85, but “they look like they’re 60,” said Dr. Deepa Shah, one of the clinic’s gastroenterologists.

Dr. Shah said that she did not believe the clinic did any screening colonoscopies on 85-year-olds. But she said there are some patients who want aggressive treatments well into their 90s, recalling a man who recently underwent chemotherapy to treat rectal cancer when he was 92.

Breast cancer politics

Of the four major cancer screenings, mammography is the most expensive — and has generated the most controversy. When a National Institutes of Health panel recommended in 1997 that women in their 40s did not need routine screenings, committee members were accused of condemning American women to death.

Two years ago, when the U.S. Preventive Services Task Force recommended essentially the same thing, the reaction was no less emotional. The suggestion remains the task force’s best known — and most contentious — stance. When some people explain why they disregard task force guidelines, they refer to its breast cancer statement. Many misinterpreted the statement to mean that women in their 40s should not have the test, Moyer said. The actual statement, which came in the middle of the health reform debates, says mammograms should not be routinely recommended to women in their 40s.

Political opposition to the recommendation even led to a little-known provision in the landmark health reform law, which ensures that insurance companies — and Medicare — will completely pay for mammograms for all women — including those in their forties. Lawmakers needed to add the provision because the health reform law eliminates copays only for preventive services tests that receive the task force’s positive “A” and “B” recommendations. Mammography screenings for women under 50 have a “C” rating, which means the task force does not recommend routinely providing the service, but “there may be considerations that support providing the service in an individual patient.”

What the task force said about mammograms for older women is not nearly as well remembered: there is insufficient evidence to recommend screenings for those 75 and over. Many breast cancers grow so slowly that older women would die of other causes before the cancer affected them, the task force said. In addition, women in this age group who do get breast cancer are more likely to get a type which is much more easily treatable, so early detection is not such a key concern.

Still, Medicare spent more than $1 billion screening these older women for breast cancer between 2003 and 2008, iWatch News found. That was 38 percent of what Medicare spent on breast cancer screening during this period.

Medicare spent more than $21 million just to test women in their 90s, the analysis discovered. In 2008, the analysis showed, at least a few dozen women 98 or older were getting mammograms.

Joan Miles, 90, says she still gets annual mammograms because “no one said I should stop.”

Miles, of Fleming Island, Fla., says she seeks out the best medical advice available, reading health newsletters, such as the respected Mayo Clinic Health Letter, and even travels to Mayo Clinic’s hospital in nearby Jacksonville, Fla., when she needs an operation. She follows a healthy regimen: eating a low-fat diet, walking two miles a day, lifting weights every week, and getting an annual physical exam.

“When I have my yearly physical, my primary always makes an appointment for me to have a mammogram, plus a full blood profile and bone scan,” she says. She says she’s never questioned the need for the test.

Some of the inappropriate breast cancer screenings have been fostered by pay-for-performance plans, which grade doctors on their cancer screening rates, experts say.

California regulators mandated cancer screenings in some health plans for a while, creating all kinds of distress among elderly patients, says Dr. Louise Walter, a geriatrics professor at University of California in San Francisco.

When Dr. Walter investigated problems at one health plan, she discovered that half of the women given mammograms had dementia and many became distressed because they did not understand what was happening to them. A 98-year-old woman became so agitated after her mammogram that her daughter refused follow-up tests.

Only two of the 216 women screened benefited from the mammograms, Walter concluded. She questioned the propriety of using cancer screening rates to measure quality of care, saying that screening women with dementia raises ethical issues. Screening such women should be assessed on a case by case basis, she says.

California eventually revised its screening policies.

Pap smear screenings

Cervical cancer screening is considered one of the greatest success stories of preventive medicine. Cervical cancer was one of the leading killers of American women until the 1950s, when women started getting Pap smear exams. Since then, the death rate has plummeted by more than 70 percent, with only about 4,000 women a year now dying from the disease.

But now, most American women get way too many of these screening tests, medical researchers say. “Roughly half of what’s being done is not a benefit to the patient,” says Philip Castle, executive director of the American Society for Clinical Pathology’s health services research institute.

The U.S. Preventive Services Task Force says women over 65 no longer need routine screenings, as long as their several latest Pap tests were normal and they are not at high risk for cervical cancer— that includes about 98

percent of all women in that age group, experts say. Unlike other cancers, cervical cancer does not occur more frequently with age; it plateaus about age 55.

Yet the iWatch News investigation found that Medicare spent about $344 million screening women 65 and older between 2003 and 2008. That’s more than 81 percent of total Medicare spending on these tests.

The task force also says that women don’t need Pap smears if they have had hysterectomies for problems unrelated to cancer.

Yet 10 million women who had their cervixes removed had unnecessary Pap smear screenings in 2002, an article in the Journal of the American Medical Association concluded. These were women with no history of cancer.

The authors conducted the study, in part, to figure out whether task force guidelines had an impact. The answer? Not really. Six years after the task force recommended against screening women with hysterectomies, the proportion of such women being screened did not decline at all, researchers found.

Maria Levada, an obstetrician and gynecologist in Valley Stream, N.Y., has performed many cervical cancer screenings on women 65 and older. She also says she has performed Pap smears on women who have had hysterectomies, despite the guidelines that say they are unnecessary.

“Patients are scared of cancer of any kind,” says Levada, adding that one-fourth of her patients are older than 65. “I have a few patients in their 90s who are sexually active with younger men.” Cervical cancer is linked to a sexually transmitted virus.

Levada says she gives Pap smears to women with hysterectomies every few years to search for cancer of the vaginal wall, she says. While she says these cancers are rare, “they are also more difficult to treat.”

But experts say such tests are unnecessary.

“It’s ridiculous,” Dr. Castle says about the prospect of these vaginal cancer tests. Vaginal cancers affect only about one in every 100,000 women, he says, and even when there’s an abnormal finding on a Pap smear, it’s unclear how to treat it. “There is zero evidence that this benefits the patient.”

As for testing sexually active women in their 90s, Stoler says that is not necessary either. Not only are these sexually-transmitted cancers slow-growing, but hormonal changes in women over 80 make it almost impossible for viruses that cause these cancers to survive.

Levada, 63, practices in Nassau County on Long Island, which she says is one of the most litigious counties in the United States. While she says she doesn’t practice defensive medicine, she adds, “It’s very hard not to order a test here and there just in case there’s a millionth of a chance you’ll miss something.”

Medicare did not begin paying for cervical cancer screening until 1990. It was a major shift for the government program, which until then had reimbursed health care providers only for cancer diagnosis and treatment.

At first, Medicare paid for patients to be screened only once every three years, and it reimbursed pathologists just $7.15 for analyzing each test sample, well under actual costs. Before long, though, pathologists began lobbying the government to double the payments. They argued that reimbursement rates were so low that laboratories would be unable to pay pathologists to analyze the tests.

Dr. James Navin, a Hawaii pathologist, launched the lobbying campaign in 1996, focusing first on trying to get Medicare administrators to raise the reimbursement rate. He worked with other pathologists to gather evidence that the rates were too low and also met with key staff members for former Vice President Al Gore and the Office of Management and Budget, according to news accounts.

When Medicare administrators rejected his request, arguing that there was not enough evidence to justify such a substantial increase, Dr. Navin turned to his congressman for help. Congress rarely passes legislation to change an individual Medicare reimbursement rate, but then-Rep. Neil Abercrombie, D-Hawaii, (now governor) proposed legislation that would do just that in 1998. Abercrombie’s office did not respond to a request for comment.

It took more than a year of lobbying, with pathologists and other physician groups first forming a coalition called People for Annual Pap Smears and later, enlisting the help of women’s groups. They cast the legislation as a women’s issue, calling one version the “Investment in Women’s Health Act.” Eventually, the reimbursement proposal got rolled into a massive budget bill, which passed Congress in November 1999. The doctors not only managed to double their reimbursement rate, they also got Medicare to increase its payment frequency, paying for patient tests every two years.

The American Society of Clinical Pathology spent $140,000 on lobbying in 1999, with some of that money supporting the reimbursement increase, lobbying records show.

Three years later, the Food and Drug Administration approved new tests that could do a better job detecting cervical cancer. Those tests could identify a strain of the sexually-transmitted human papillomavirus (HPV), which researchers had discovered caused virtually all cervical cancer.

The new HPV tests can detect 99

percent of cervical cancers and need to be repeated only every three to five years. By contrast, the Pap test had to be repeated annually because it had such a large error rate, missing as many as 30 percent of cancers.

Even though the HPV tests have been on the market now for eight years, medical practice has barely budged. Only 19 percent of doctors surveyed said they would wait three years to conduct a Pap test, after negative findings on both Pap and HPV tests, a recent study found.

“Sixty million women get Paps every year,” says Dr. Mark Schiffman, a senior investigator at the National Cancer Institute.. “A large percentage do not need to be getting them.”

Gynecologists may say publicly that patients insist on getting annual Pap smears or that they need annual wellness exams. But privately, doctors admit that they could never meet their revenue goals if these annual medical rituals disappeared, said Castle of the American Society for Clinical Pathology. The hunt for cervical cancer generates between $4 billion and $6 billion a year, he says.

The HPV tests, meanwhile, have resulted in a boondoggle of their own. For a while, doctors ordered two types of HPV tests on all patients: tests for low-risk HPVs and tests for high-risk HPVs. But then, researchers discovered that the tests for low-risk HPV did not detect cancer at all.

“Any money that’s spent on this test is wasted,” Dr. Stoler says.

Medical experts have spent years trying to get the government to either take the low-risk test off the market or refuse to pay for it. But Medicare administrators have been too preoccupied with other issues to deal with the reimbursement question, Castle says. The FDA cannot remove the tests from the market unless there is “specific evidence reported to them that the tests are harmful to patients,” a spokeswoman says.

Castle says he is concerned that some cancers are going undiagnosed because people are getting the wrong HPV test, but cannot prove that is happening.

Castle and other experts have also tried to convince Qiagen, the company that makes the test, to withdraw it from the market. But Qiagen refuses, they say, because researchers continue to order the tests.

Some doctors say that Qiagen’s sales representatives tell them that the tests remain valid, says Dr. Ann Moriarty, an Indianapolis pathologist.

Shelley Ducker, a Qiagen spokeswoman, says the company only promotes the test for high-risk HPVs to clinicians. But it keeps the test for low-risk HPVs on the market for scientists and industry researchers, who are studying different HPV strains and their role in various diseases. Some doctors who analyze HPV tests, though, are infuriated. Dr. Dina Mody, medical director of cytology at Methodist Hospital in Houston, says she is so frustrated by the confusion that she calls every doctor who orders the low-risk test to explain there is no clinical indication for it.

She says that she’s heard all kinds of crazy things, like one doctor telling her his patient insisted on the test because she thought results would show whether her boyfriend was cheating on her.

She now refuses to perform the tests, even though she’s lost several doctors’ business.

“I’m not going to do these tests, if there’s no clinical indication,” she says. “Why waste money?”

Data editor David Donald contributed to this story.

Research methodology

2011-10-07T04:18:01-04:00

The Center analyzed Medicare claims data obtained from the Centers for Medicare and Medicaid Services (CMS). For the analysis on the four cancer screening tests, the Center used a subset of the data submitted by physicians, hospitals and clinics from 2003 to 2008, the last year available at the time the data were acquired. Denied claims were excluded.

For privacy purposes and other reasons, the Center was limited to a 5 percent sample of national Medicare Part B data that contain claims for medical procedures, such as routine screenings, and used mainly by researchers and consultants. Besides limitations of sampling, the data have only the quarter in which a procedure was performed, not actual dates. And a permanent federal injunction prevents naming individual doctors who received payment for the claims.

Results from the 5 percent sample were multiplied by 20 to give a national scope to analyzed trends, an accepted survey research technique. However, even with a sample this large, it is impossible to account for all types of errors in the data. This means all calculations are estimates and rounded and must be considered imprecise.

The analysis of Medicare claims for prostate, cervical, colon and breast cancer screenings was based on procedure codes obtained from documents and guidelines put out by CMS and the U.S. Preventive Services Task Force, a panel of medical experts. Some codes were also confirmed by professionals in the field.

The codes represent a number of different procedures for each type of cancer screening. Colon cancer screenings include screening colonoscopies, sigmoidoscopies, barium enemas and fecal occult blood tests. Cervical cancer screenings include both Papanicolaou smears and liquid-based cytology. Breast cancer screenings include both film and digital mammograms, and prostate cancer screenings include digital rectal exams as well as prostate-specific antigen tests.

The Preventive Services Task Force notes that high risk patients over 65 are excluded from its recommendation against getting routine cervical cancer screenings. After consulting with doctors and available documentation from CMS, we excluded any cervical cancer screening claims for which the high risk code ‘V1589’ was included in the diagnosis.

The Center relied on the number of claims billed to indicate trends and frequency for the corresponding test. However, a claim cannot be equated with a procedure. Certain procedures can be billed in multiple claims. This likely results in a higher number of claims than procedures, making it difficult if not impossible to calculate cost per procedure.

To protect patients’ identities, some information, such as the date of a claim, was removed from the data, making it impossible to isolate procedures.

The overall price for each test included the payments Medicare made to physicians, hospitals, clinics and laboratories. According to CMS’s Research Data Assistance Center (ResDAC), some claims (about 5 percent of the claims analyzed) incorrectly include a small amount of interest on the first line of payment. Therefore the payment amounts, like all else in the data, cannot be considered exact.

For the total mammography cost, the Center included the amount of money Medicare paid for computer-aided detection (CAD), an optional add-on that highlights for radiologists areas on a screening image that may contain tumors.