Nursing Homes Seek Exemptions From Health Law

在 ServiceModel 客户端配置部分中，找不到引用协定“TranslatorService.LanguageService”的默认终结点元素。这可能是因为未找到应用程序的配置文件，或者是因为客户端元素中找不到与此协定匹配的终结点元素。
在 ServiceModel 客户端配置部分中，找不到引用协定“TranslatorService.LanguageService”的默认终结点元素。这可能是因为未找到应用程序的配置文件，或者是因为客户端元素中找不到与此协定匹配的终结点元素。

The numbers are stark. Among workers who provide hands-on care to nursing home residents, one in four has no health insurance. Among those who provide care to people living at home, one in three is uninsured.

The new health care law is supposed to fix the problem by guaranteeing access to affordable coverage for all. But many nursing homes and home care agencies, alarmed at the cost of providing health insurance to hundreds of thousands of health care workers, have started a lobbying effort seeking some kind of exemption or special treatment.

Mark Parkinson, president of the American Health Care Association, the largest trade group for nursing homes, says the problem is that reimbursement rates for Medicaid and Medicare, set by government agencies, do not pay them enough to offer their employees medical coverage. “We do not have much ability to increase prices because we are so dependent on Medicaid and Medicare” for revenue, he said.

Mr. Parkinson acknowledged that when nursing homes do offer health insurance to employees, the benefits are often limited. The coverage “is probably not up to what will be required” by the federal law, he said.

Medicaid covers about two-thirds of nursing home residents. States set Medicaid rates, and many states, facing severe budget problems, have reduced payments for nursing homes.

Starting in 2014, the law will require employers with 50 or more full-time employees to offer affordable coverage or risk paying a penalty. For a midsize nursing home, that penalty could easily exceed $200,000 a year. Nursing home executives are urging Congress and the Obama administration to spare them from the penalties.

Vanessa Valerio, 25, a certified nursing assistant who earns $10 an hour at Lakeview Christian Home in Carlsbad, N.M., said she was uninsured because she could not afford the coverage offered by her employer.

The chief executive of the Lakeview nursing home, Joanna D. Knox, said the company used to pay the entire premium for employees. It now requires workers to pay $25 of the $585 monthly premium for individual coverage.

“When we started charging $25 a month,” Ms. Knox said, “many employees dropped coverage.” Of the home’s 200 employees, only 87 have elected it, she said, adding, “I don’t know how we could possibly absorb the additional cost of providing coverage for the other employees.”

Charlene A. Harrington, a professor at the School of Nursing at the University of California, San Francisco, said it would be a mistake for Congress or the administration to relieve nursing homes of the obligation to provide coverage to employees.

“It’s scandalous to have nursing home employees taking care of people when they themselves lack coverage and go without care,” Ms. Harrington said. “If employees have health insurance, they are more likely to be treated for illnesses, less likely to pass on infections to nursing home residents and more likely to get early treatment for occupational injuries.”

The rate of injuries in nursing homes is about twice the rate for all occupations, according to the Labor Department. Back injuries are common among those who lift patients and help them get in and out of bed.

Since the law was signed 14 months ago, the focus of lobbying has shifted. A tumultuous battle over the future of the health care system has given way to more concentrated efforts to undo or rewrite particular provisions.

Mr. Parkinson, a former Democratic governor of Kansas who is now the top Washington lobbyist for nursing homes, is pushing several ideas.

One option would give nursing homes more time to comply with the requirement to offer coverage. Another proposal, according to a list of options prepared by lobbyists for the industry, would waive or reduce the penalties for nursing homes “placed in financial distress as a result of the new mandates and fines.” Alternatively, Mr. Parkinson said, Congress could allow nursing homes to take tax deductions for the penalties, which under the 2010 law are nondeductible.

View the original article here

Appellate Court Hears Defense of Health Law

The 14 members of the United States Court of Appeals for the Fourth Circuit, the first appellate court to review the law, are evenly divided as appointees of Democratic and Republican presidents. That puts the odds of drawing three Democratic appointees in the computerized lottery at roughly 10 to 1. Lawyers do not learn the makeup of the panel until the day of the hearing.

The party of the appointing president is not necessarily predictive of a federal judge’s leanings. But in five decisions in lower courts, three Democratic-appointed judges have upheld the Affordable Care Act while two Republican-appointed judges have ruled that its central provision — the requirement that most Americans obtain health insurance — is unconstitutional.

At Tuesday’s hearing in Richmond, the three Fourth Circuit judges — Diana Gribbon Motz, who was appointed by President Bill Clinton, and the two Obama appointees, Andre M. Davis and James A. Wynn Jr. — challenged both sides with pointed questioning. The hearing lasted more than two hours.

As in the lower courts, the judges focused on the novel question of how to define the choice not to buy health insurance: as commercial activity that the Supreme Court has ruled can be regulated, or as inactivity that is beyond Congress’s reach.

They also devoted considerable time to discussing whether Virginia’s attorney general had legal standing to challenge the insurance mandate, because it would impose a requirement on individuals but not on states.

Virginia stakes its right to sue on its enactment of a state law aimed at exempting residents from the insurance requirement, thereby creating a conflict with federal law.

“If you adopted this theory of standing,” argued Neal K. Katyal, the acting United States solicitor general, “you would allow, for example, a state that was opposed to the war in Afghanistan to say our citizens should be exempt and file a lawsuit on that basis.”

The Fourth Circuit panel heard the appeals of two challenges to the health care act that yielded opposite results late last year.

In one challenge, by Attorney General Kenneth T. Cuccinelli II of Virginia, Judge Henry E. Hudson of Federal District Court in Richmond ruled that by requiring most Americans to buy insurance — a commercial product — the mandate exceeded Congress’s authority to regulate interstate commerce. In the other, filed by Liberty University, Judge Norman K. Moon of Federal District Court in Lynchburg, Va., found that the mandate fell comfortably within “well-settled principles” set by the Supreme Court.

The Virginia health care cases are the first of four scheduled for appellate hearings during the next five weeks. The Court of Appeals for the Sixth Circuit, in Cincinnati, will hear arguments on June 1 in the appeal of a ruling upholding the law. A week later, the Court of Appeals for the 11th Circuit, in Atlanta, will hear the Obama administration’s appeal of a Florida judge’s ruling that invalidated the entire act. That judge suspended his ruling until appellate courts could hear the case.

It is widely anticipated that the Supreme Court will ultimately settle the matter, although it is not clear which of several cases it might take. That may depend on how and when the appeals courts rule.

If, for instance, the three-judge panel rules against Virginia, the commonwealth expects to appeal directly to the Supreme Court without requesting a hearing before the full Fourth Circuit bench, Mr. Cuccinelli, a Republican, said on Tuesday. But if the Fourth Circuit rules that Virginia does not have standing to challenge the law, the Supreme Court could wait for a case that gives it a more focused look at the central issues.

In Tuesday’s hearing, Mr. Katyal slightly shifted the emphasis in the government’s defense of the health law. He tried to steer the judges away from a semantic focus on whether a failure to buy health insurance constituted activity or inactivity, a question that has divided the lower courts.

Past Supreme Court decisions have backed Congress’s authority under the Constitution’s Commerce Clause to regulate “activities” that have a substantial effect on interstate commerce. But the court has never considered whether the term can be defined so broadly as to include decisions not to do something.

Mr. Katyal argued instead that the activity being regulated by the health care law is merely the means of payment by Americans who will inevitably enter the health care market and who will shift costs to others if they are not insured.

“Congress is not asking people to buy something they would not otherwise buy,” Mr. Katyal said.

Mathew D. Staver, the dean of Liberty University’s law school, disputed that assertion. The health care act, Mr. Staver said, “forces inactive bystanders into the stream of commerce.”

 

Appellate Court Hears Defense of Health Law

The 14 members of the United States Court of Appeals for the Fourth Circuit, the first appellate court to review the law, are evenly divided as appointees of Democratic and Republican presidents. That puts the odds of drawing three Democratic appointees in the computerized lottery at roughly 10 to 1. Lawyers do not learn the makeup of the panel until the day of the hearing.

The party of the appointing president is not necessarily predictive of a federal judge’s leanings. But in five decisions in lower courts, three Democratic-appointed judges have upheld the Affordable Care Act while two Republican-appointed judges have ruled that its central provision — the requirement that most Americans obtain health insurance — is unconstitutional.

At Tuesday’s hearing in Richmond, the three Fourth Circuit judges — Diana Gribbon Motz, who was appointed by President Bill Clinton, and the two Obama appointees, Andre M. Davis and James A. Wynn Jr. — challenged both sides with pointed questioning. The hearing lasted more than two hours.

As in the lower courts, the judges focused on the novel question of how to define the choice not to buy health insurance: as commercial activity that the Supreme Court has ruled can be regulated, or as inactivity that is beyond Congress’s reach.

They also devoted considerable time to discussing whether Virginia’s attorney general had legal standing to challenge the insurance mandate, because it would impose a requirement on individuals but not on states.

Virginia stakes its right to sue on its enactment of a state law aimed at exempting residents from the insurance requirement, thereby creating a conflict with federal law.

“If you adopted this theory of standing,” argued Neal K. Katyal, the acting United States solicitor general, “you would allow, for example, a state that was opposed to the war in Afghanistan to say our citizens should be exempt and file a lawsuit on that basis.”

The Fourth Circuit panel heard the appeals of two challenges to the health care act that yielded opposite results late last year.

In one challenge, by Attorney General Kenneth T. Cuccinelli II of Virginia, Judge Henry E. Hudson of Federal District Court in Richmond ruled that by requiring most Americans to buy insurance — a commercial product — the mandate exceeded Congress’s authority to regulate interstate commerce. In the other, filed by Liberty University, Judge Norman K. Moon of Federal District Court in Lynchburg, Va., found that the mandate fell comfortably within “well-settled principles” set by the Supreme Court.

The Virginia health care cases are the first of four scheduled for appellate hearings during the next five weeks. The Court of Appeals for the Sixth Circuit, in Cincinnati, will hear arguments on June 1 in the appeal of a ruling upholding the law. A week later, the Court of Appeals for the 11th Circuit, in Atlanta, will hear the Obama administration’s appeal of a Florida judge’s ruling that invalidated the entire act. That judge suspended his ruling until appellate courts could hear the case.

It is widely anticipated that the Supreme Court will ultimately settle the matter, although it is not clear which of several cases it might take. That may depend on how and when the appeals courts rule.

If, for instance, the three-judge panel rules against Virginia, the commonwealth expects to appeal directly to the Supreme Court without requesting a hearing before the full Fourth Circuit bench, Mr. Cuccinelli, a Republican, said on Tuesday. But if the Fourth Circuit rules that Virginia does not have standing to challenge the law, the Supreme Court could wait for a case that gives it a more focused look at the central issues.

In Tuesday’s hearing, Mr. Katyal slightly shifted the emphasis in the government’s defense of the health law. He tried to steer the judges away from a semantic focus on whether a failure to buy health insurance constituted activity or inactivity, a question that has divided the lower courts.

Past Supreme Court decisions have backed Congress’s authority under the Constitution’s Commerce Clause to regulate “activities” that have a substantial effect on interstate commerce. But the court has never considered whether the term can be defined so broadly as to include decisions not to do something.

Mr. Katyal argued instead that the activity being regulated by the health care law is merely the means of payment by Americans who will inevitably enter the health care market and who will shift costs to others if they are not insured.

“Congress is not asking people to buy something they would not otherwise buy,” Mr. Katyal said.

Mathew D. Staver, the dean of Liberty University’s law school, disputed that assertion. The health care act, Mr. Staver said, “forces inactive bystanders into the stream of commerce.”

 

Appellate Court Hears Defense of Health Law

The 14 members of the United States Court of Appeals for the Fourth Circuit, the first appellate court to review the law, are evenly divided as appointees of Democratic and Republican presidents. That puts the odds of drawing three Democratic appointees in the computerized lottery at roughly 10 to 1. Lawyers do not learn the makeup of the panel until the day of the hearing.

The party of the appointing president is not necessarily predictive of a federal judge’s leanings. But in five decisions in lower courts, three Democratic-appointed judges have upheld the Affordable Care Act while two Republican-appointed judges have ruled that its central provision — the requirement that most Americans obtain health insurance — is unconstitutional.

At Tuesday’s hearing in Richmond, the three Fourth Circuit judges — Diana Gribbon Motz, who was appointed by President Bill Clinton, and the two Obama appointees, Andre M. Davis and James A. Wynn Jr. — challenged both sides with pointed questioning. The hearing lasted more than two hours.

As in the lower courts, the judges focused on the novel question of how to define the choice not to buy health insurance: as commercial activity that the Supreme Court has ruled can be regulated, or as inactivity that is beyond Congress’s reach.

They also devoted considerable time to discussing whether Virginia’s attorney general had legal standing to challenge the insurance mandate, because it would impose a requirement on individuals but not on states.

Virginia stakes its right to sue on its enactment of a state law aimed at exempting residents from the insurance requirement, thereby creating a conflict with federal law.

“If you adopted this theory of standing,” argued Neal K. Katyal, the acting United States solicitor general, “you would allow, for example, a state that was opposed to the war in Afghanistan to say our citizens should be exempt and file a lawsuit on that basis.”

The Fourth Circuit panel heard the appeals of two challenges to the health care act that yielded opposite results late last year.

In one challenge, by Attorney General Kenneth T. Cuccinelli II of Virginia, Judge Henry E. Hudson of Federal District Court in Richmond ruled that by requiring most Americans to buy insurance — a commercial product — the mandate exceeded Congress’s authority to regulate interstate commerce. In the other, filed by Liberty University, Judge Norman K. Moon of Federal District Court in Lynchburg, Va., found that the mandate fell comfortably within “well-settled principles” set by the Supreme Court.

The Virginia health care cases are the first of four scheduled for appellate hearings during the next five weeks. The Court of Appeals for the Sixth Circuit, in Cincinnati, will hear arguments on June 1 in the appeal of a ruling upholding the law. A week later, the Court of Appeals for the 11th Circuit, in Atlanta, will hear the Obama administration’s appeal of a Florida judge’s ruling that invalidated the entire act. That judge suspended his ruling until appellate courts could hear the case.

It is widely anticipated that the Supreme Court will ultimately settle the matter, although it is not clear which of several cases it might take. That may depend on how and when the appeals courts rule.

If, for instance, the three-judge panel rules against Virginia, the commonwealth expects to appeal directly to the Supreme Court without requesting a hearing before the full Fourth Circuit bench, Mr. Cuccinelli, a Republican, said on Tuesday. But if the Fourth Circuit rules that Virginia does not have standing to challenge the law, the Supreme Court could wait for a case that gives it a more focused look at the central issues.

In Tuesday’s hearing, Mr. Katyal slightly shifted the emphasis in the government’s defense of the health law. He tried to steer the judges away from a semantic focus on whether a failure to buy health insurance constituted activity or inactivity, a question that has divided the lower courts.

Past Supreme Court decisions have backed Congress’s authority under the Constitution’s Commerce Clause to regulate “activities” that have a substantial effect on interstate commerce. But the court has never considered whether the term can be defined so broadly as to include decisions not to do something.

Mr. Katyal argued instead that the activity being regulated by the health care law is merely the means of payment by Americans who will inevitably enter the health care market and who will shift costs to others if they are not insured.

“Congress is not asking people to buy something they would not otherwise buy,” Mr. Katyal said.

Mathew D. Staver, the dean of Liberty University’s law school, disputed that assertion. The health care act, Mr. Staver said, “forces inactive bystanders into the stream of commerce.”

 

Appellate Court Hears Defense of Health Law

The 14 members of the United States Court of Appeals for the Fourth Circuit, the first appellate court to review the law, are evenly divided as appointees of Democratic and Republican presidents. That puts the odds of drawing three Democratic appointees in the computerized lottery at roughly 10 to 1. Lawyers do not learn the makeup of the panel until the day of the hearing.

The party of the appointing president is not necessarily predictive of a federal judge’s leanings. But in five decisions in lower courts, three Democratic-appointed judges have upheld the Affordable Care Act while two Republican-appointed judges have ruled that its central provision — the requirement that most Americans obtain health insurance — is unconstitutional.

At Tuesday’s hearing in Richmond, the three Fourth Circuit judges — Diana Gribbon Motz, who was appointed by President Bill Clinton, and the two Obama appointees, Andre M. Davis and James A. Wynn Jr. — challenged both sides with pointed questioning. The hearing lasted more than two hours.

As in the lower courts, the judges focused on the novel question of how to define the choice not to buy health insurance: as commercial activity that the Supreme Court has ruled can be regulated, or as inactivity that is beyond Congress’s reach.

They also devoted considerable time to discussing whether Virginia’s attorney general had legal standing to challenge the insurance mandate, because it would impose a requirement on individuals but not on states.

Virginia stakes its right to sue on its enactment of a state law aimed at exempting residents from the insurance requirement, thereby creating a conflict with federal law.

“If you adopted this theory of standing,” argued Neal K. Katyal, the acting United States solicitor general, “you would allow, for example, a state that was opposed to the war in Afghanistan to say our citizens should be exempt and file a lawsuit on that basis.”

The Fourth Circuit panel heard the appeals of two challenges to the health care act that yielded opposite results late last year.

In one challenge, by Attorney General Kenneth T. Cuccinelli II of Virginia, Judge Henry E. Hudson of Federal District Court in Richmond ruled that by requiring most Americans to buy insurance — a commercial product — the mandate exceeded Congress’s authority to regulate interstate commerce. In the other, filed by Liberty University, Judge Norman K. Moon of Federal District Court in Lynchburg, Va., found that the mandate fell comfortably within “well-settled principles” set by the Supreme Court.

The Virginia health care cases are the first of four scheduled for appellate hearings during the next five weeks. The Court of Appeals for the Sixth Circuit, in Cincinnati, will hear arguments on June 1 in the appeal of a ruling upholding the law. A week later, the Court of Appeals for the 11th Circuit, in Atlanta, will hear the Obama administration’s appeal of a Florida judge’s ruling that invalidated the entire act. That judge suspended his ruling until appellate courts could hear the case.

It is widely anticipated that the Supreme Court will ultimately settle the matter, although it is not clear which of several cases it might take. That may depend on how and when the appeals courts rule.

If, for instance, the three-judge panel rules against Virginia, the commonwealth expects to appeal directly to the Supreme Court without requesting a hearing before the full Fourth Circuit bench, Mr. Cuccinelli, a Republican, said on Tuesday. But if the Fourth Circuit rules that Virginia does not have standing to challenge the law, the Supreme Court could wait for a case that gives it a more focused look at the central issues.

In Tuesday’s hearing, Mr. Katyal slightly shifted the emphasis in the government’s defense of the health law. He tried to steer the judges away from a semantic focus on whether a failure to buy health insurance constituted activity or inactivity, a question that has divided the lower courts.

Past Supreme Court decisions have backed Congress’s authority under the Constitution’s Commerce Clause to regulate “activities” that have a substantial effect on interstate commerce. But the court has never considered whether the term can be defined so broadly as to include decisions not to do something.

Mr. Katyal argued instead that the activity being regulated by the health care law is merely the means of payment by Americans who will inevitably enter the health care market and who will shift costs to others if they are not insured.

“Congress is not asking people to buy something they would not otherwise buy,” Mr. Katyal said.

Mathew D. Staver, the dean of Liberty University’s law school, disputed that assertion. The health care act, Mr. Staver said, “forces inactive bystanders into the stream of commerce.”

 

Battle Over Health Care Law Shifts to Federal Appellate Courts

At Tuesday’s hearing, the United States Court of Appeals for the Fourth Circuit will consider a pair of contradictory rulings sent up from the lower courts. In one case, filed by Virginia’s attorney general, a federal district judge in Richmond ruled late last year that Congress had exceeded its authority by requiring most Americans to obtain health insurance. In the other, filed by Liberty University, a conservative Christian institution, a district judge sitting 100 miles away in Lynchburg, Va., upheld the insurance mandate.

If the appellate courts act quickly, the question of the health law’s constitutionality could land before the Supreme Court as soon as the next term, which opens in October.

With the lower courts divided, each side hopes to build a string of victories in the midlevel Courts of Appeals.

“We want to win as many of these as we can,” said Attorney General Kenneth T. Cuccinelli II of Virginia, a Republican. “If we have nothing but wins all the way up to the Supreme Court, there is an element of momentum, I think, where the justices consider what has gone on before the case came to them.”

Since the enactment of the Affordable Care Act in March 2010, 31 lawsuits have been filed to challenge it, according to the Justice Department, which is defending the Obama administration. Nine are awaiting action by Courts of Appeals, and nine are pending in federal district courts. The others have been dismissed.

Three district judges appointed by Democratic presidents have upheld the law while two Republican appointees have struck down part or all of it.

On June 1, the Court of Appeals for the Sixth Circuit in Cincinnati is scheduled to hear the appeal of a ruling in favor of the law. On June 8, the Court of Appeals for the 11th Circuit in Atlanta will review a Florida judge’s ruling that invalidated the entire act. That judge later suspended his own order until higher courts could settle the matter.

The Supreme Court recently turned down a request by Mr. Cuccinelli that it hear the case without review by the Court of Appeals.

In Tuesday’s hearing, a three-judge panel will first hear arguments in the case filed by Liberty University and then in the one filed by Mr. Cuccinelli. The makeup of the randomly selected panel will not be revealed until Tuesday morning.

With the addition of four appointees by President Obama, the Fourth Circuit bench now includes seven members named by Democratic presidents and seven named by Republicans. The loser before the three-judge panel may petition for a hearing before the entire court before taking the case to the Supreme Court.

The Obama administration will be represented in each of the appellate cases by Neal K. Katyal, the acting solicitor general.

Solicitors general more typically argue for the federal government before the Supreme Court. Although it is not unprecedented for them to appear before Courts of Appeals, Mr. Katyal’s assignment is seen as a nod to the significance of the case.

E. Duncan Getchell Jr., Virginia’s solicitor general, will speak for the commonwealth, as he did in the district court, and Liberty University will be represented by Mathew D. Staver, the dean of its law school.

The plaintiffs in the 11th Circuit case, including Republican officials from 26 states, will be represented by Paul D. Clement, a United States solicitor general under President George W. Bush. Mr. Clement recently resigned from King & Spalding after it withdrew its support for his defense of a federal law banning recognition of same-sex marriages.

Scores of politicians, economists and interest groups have filed friend-of-the-court briefs on both sides of the health care litigation.

The Virginia and Liberty University cases bear some differences. But both challenge the insurance requirement on the ground that it cannot be supported by the commerce clause of the United States Constitution, which gives Congress broad but not unlimited authority to regulate interstate commerce. Starting in 2014, the health care law would require most Americans to obtain policies or pay an income tax penalty.

The plaintiffs complain that the government has never before forced citizens to buy a commercial product. In the lower courts, arguments have centered on whether a choice to not buy insurance constitutes the kind of economic “activity” that the Supreme Court has, in the past, found subject to federal regulation.

The judges are also being asked to determine whether Virginia has legal standing to challenge the law, whether the insurance requirement can be supported under Congress’s authority to tax, whether it runs afoul of religious liberties, whether employers can be required to contribute to their workers’ health coverage, and whether a finding against one provision of the law should invalidate the entire act.

 

Personal Health: ‘Disease of Kings’ Trickles Down to the Rest

 

Long regarded as a “disease of kings” for its association with a diet rich in meats and alcohol, gout in modern times has become a decidedly more plebeian disorder. More than six million adults in the United States have had it, and the numbers are rising steadily as the population ages, becomes heavier and is exposed to foods and other substances that can precipitate the disorder in susceptible people.

And while historically gout has been a male disease (three-fourths of cases occur in men), the incidence has been rising in older women, with as many as one in 20 over age 70 now afflicted.

Fortunately for my neighbor, the fiery pain in his toe subsided in a few days, and while he has no idea what brought on the attack, he said he’s now “eating more healthfully.” Unfortunately, although some people never experience a second attack, others can suffer recurrences several times a year.

Gout Causes and Risks

Recurrent attacks are more likely if the underlying cause of gout is not treated. That cause is a high blood level of uric acid that forms irritating urate crystals that lodge in joints or soft tissues, causing intense pain.

Uric acid is produced when the body metabolizes purines, common components of many foods, especially organ meats, anchovies, herring, asparagus and mushrooms. Other dietary contributors include excessive consumption of alcohol and possibly soft drinks containing fructose.

A study published in November in The Journal of the American Medical Association linked an increased intake of sugar-sweetened soda to a raised risk of gout in women, who until menopause are relatively protected against the disease by estrogen, which helps the body excrete uric acid.

Elevated levels of uric acid can result either from the body’s overproduction of the substance or, more commonly, from an inability of the kidneys to excrete it adequately. Dr. Tuhina Neogi, a rheumatologist at the Boston University School of Medicine, explained that humans lack the enzyme uricase, present in most other animals, and thus are unable to convert urate into allantoin, the soluble end-product of purine metabolism.

Dr. Neogi noted recently in The New England Journal of Medicine that simply having a high level of uric acid is not, by itself, enough to cause gout. “Other factors play a contributing role,” she said in an interview.

As sometimes happens, the treatment of one disease can cause another. Among the medications linked to an increase risk of developing gout are thiazide diuretics, the first line of drug treatment for high blood pressure; cyclosporine, an immunosuppressant drug used to prevent organ rejection in transplant patients; and low-dose aspirin, commonly taken to reduce the risk of heart attack and stroke. (On the other hand, aspirin in high doses — three or more grams a day — protects against gout by increasing uric acid excretion, Dr. Neogi wrote.

Even drugs used to lower uric acid levels long-term can initially provoke an attack of gout, presumably by mobilizing body stores of urate, she said.

The risk of gout is also higher among people with disorders that are increasingly common in modern society, including hypertension, diabetes, high cholesterol, atherosclerosis and congestive heart failure. Obesity and the so-called metabolic syndrome, which includes insulin resistance, are other common factors that can make an attack of gout more likely.

People with a family history of gout also are at greater risk of developing it. Several genes have been linked to the disease.

Diagnosis and Treatment

Dr. Neogi noted that people vary in their response to uric acid. High blood levels are not always present during an attack of gout, she said, and some people with high levels never develop the disease.

Although symptoms are usually quite characteristic — rapid development of severe pain, redness and swelling, most often in the first joint of the big toe — a more certain diagnosis requires detection of urate crystals in an inflamed joint during an attack or between attacks. As this involves drawing fluid from the affected joint, it is not often done in routine medical practice, she said.

Sometimes in older people, especially women, multiple joints can be involved, leading to a mistaken diagnosis of rheumatoid arthritis.

If gout is untreated and the disease becomes advanced, deposits of urate crystals may form into nodules called tophi beneath the skin. While usually not painful, tophi can become swollen and tender during flare-ups of gout. Urate deposits may also cause kidney stones.

Treatment necessarily begins with lifestyle modifications, especially dietary changes to limit the intake of purines, which means avoiding organ meats and consuming other meats, poultry and seafood in limited amounts (a mere four to six ounces a day). Better to rely more on low-fat dairy, eggs and vegetarian sources of protein like tofu and nut butters.

In the beverage department, alcohol is best avoided (or limited to one drink a day, if that) and sugary soft drinks avoided altogether. They are nothing more than empty calories. Diet soda, however, is not a problem, at least not with regard to gout.

Caffeine appears to be protective; routine high intake of coffee (and perhaps also tea) can lower uric acid levels. Patients have also reported that cherry juice (or eating cherries or other dark-colored fruits, like purple grapes and blueberries) may be protective and prevent recurrences.

It is most helpful to drink lots of water throughout the day — one to two liters, plus another one to two liters of other liquids — to limit the buildup of urate and keep kidneys flushed.

In terms of medication, my neighbor did the right thing when his gout attack occurred. He took a hefty dose (800 milligrams) of ibuprofen, an over-the-counter nonsteroidal anti-inflammatory drug (Advil and Motrin are common brand names), to reduce the pain and inflammation in his affected joint.

Had he seen a doctor, he might have been prescribed colchicine, which is most effective if taken soon after gout symptoms develop. Unfortunately, this medication can cause side effects, like nausea, vomiting and diarrhea, that limit its usefulness.

If neither of these medications can be used, a corticosteroid like prednisone may be taken orally or injected into the affected joint to reduce pain and inflammation.

Patients who experience frequent attacks may require continuing treatment with urate-lowering drugs called xanthine oxidase inhibitors, like allopurinol and febuxostat, which reduce the amount of uric acid the body produces. Another drug, probenecid, helps the kidneys excrete uric acid.

 

Recipes for Health: A Lighter, Lovelier Garlic

 

This was green garlic, freshly harvested. By now it should be available at most farmers’ markets. At some stands, the bulbs look a lot like spring onions, or even leeks, because they haven’t set cloves yet. Once the cloves appear, the garlic looks more familiar; still, the green stems will be attached, and you must remove several layers of moist skin to get to the cloves.

The season doesn’t last long, so I buy green garlic every week and use it in all manner of dishes. Because it’s milder than mature garlic, you can use a lot without overpowering a dish.

Many researchers believe garlic, green or mature, may help lower cholesterol, triglyceride levels and blood pressure. Some of its constituents, including allicin, vitamin C, vitamin B6, manganese and selenium, may provide cardiovascular benefits.

Some people are so enthusiastic about these therapeutic properties that they take garlic supplements. It’s hardly necessary; it’s easy to get all you want in everyday dishes.

Green Garlic, Potato and Leek Soup

A very pale green springtime cousin of vichyssoise, this puree is comforting when served hot, refreshing when cold.

3/4 pound green garlic (weight includes stalks)

2 tablespoons extra virgin olive oil

1 pound leeks, white and light green parts only, rinsed thoroughly and sliced

1 small celery rib, sliced (about 1/4 cup)

Salt to taste

1 pound Yukon gold or russet potatoes, peeled and diced

1 1/2 quarts water, vegetable stock or chicken stock

A bouquet garni made with a bay leaf and 2 sprigs each thyme and parsley

Freshly ground pepper

1/4 cup chopped fresh flat leaf parsley, chervil, or tarragon

1. Trim off the tough green ends of the garlic bulbs. If the garlic has formed cloves, separate them and remove the thick shells from the tender cloves. If it has not formed cloves, just remove the outside layers. Chop coarsely. You should have about 1 cup chopped green garlic.

2. Heat the olive oil in a large, heavy soup pot over medium heat. Add the leeks, green garlic, celery and 1/2 teaspoon salt. Cook gently for five to 10 minutes until the vegetables have softened but not colored. Add the potatoes, water, bouquet garni and salt to taste. Bring to a boil, reduce the heat, cover and simmer 30 minutes.

3. Puree the soup using an immersion blender. Alternatively, use puree in a standing blender working in 1 1/2 cup batches; pull a towel tightly over the top, rather than a tight-fitting lid, in order to prevent splashes. Put through a medium strainer, pressing the soup through with the back of a ladle or with a pestle. Reheat, taste and adjust salt. Add freshly ground pepper. Ladle into soup bowls, and sprinkle chopped fresh parsley, chervil or chopped fresh tarragon over each serving. Alternatively, chill and serve cold. You can thin out if you wish with milk or stock.

Yield: Serves six.

Advance preparation: You can make this a day ahead and reheat. You may want to thin the soup with a little milk or stock.

Nutritional information per serving: 135 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 3 grams monounsaturated fat; 0 milligrams cholesterol; 21 grams carbohydrates; 4 grams dietary fiber; 45 milligrams sodium (does not include salt to taste); 2 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."