Medicare paid $5.1B for poor nursing home care

SAN FRANCISCO (AP) — Medicare paid billions in taxpayer dollars to nursing homes nationwide that were not meeting basic requirements to look after their residents, government investigators have found.

The report, released Thursday by the Department of Health and Human Services' inspector general, said Medicare paid about $5.1 billion for patients to stay in skilled nursing facilities that failed to meet federal quality of care rules in 2009, in some cases resulting in dangerous and neglectful conditions.

One out of every three times patients wound up in nursing homes that year, they landed in facilities that failed to follow basic care requirements laid out by the federal agency that administers Medicare, investigators estimated.

By law, nursing homes need to write up care plans specially tailored for each resident, so doctors, nurses, therapists and all other caregivers are on the same page about how to help residents reach the highest possible levels of physical, mental and psychological well-being.

Not only are residents often going without the crucial help they need, but the government could be spending taxpayer money on facilities that could endanger people's health, the report concluded. The findings come as concerns about health care quality and cost are garnering heightened attention as the Obama administration implements the nation's sweeping health care overhaul.

"These findings raise concerns about what Medicare is paying for," the report said.

Investigators estimate that in one out of five stays, patients' health problems weren't addressed in the care plans, falling far short of government directives. For example, one home made no plans to monitor a patient's use of two anti-psychotic drugs and one depression medication, even though the drugs could have serious side effects.

In other cases, residents got therapy they didn't need, which the report said was in the nursing homes' financial interest because they would be reimbursed at a higher rate by Medicare.

In one example, a patient kept getting physical and occupational therapy even though the care plan said all the health goals had been met, the report said.

The Office of Inspector General's report was based on medical records from 190 patient visits to nursing homes in 42 states that lasted at least three weeks, which investigators said gave them a statistically valid sample of Medicare beneficiaries' experiences in skilled nursing facilities.

That sample represents about 1.1 million patient visits to nursing homes nationwide in 2009, the most recent year for which data was available, according to the review.

Overall, the review raises questions about whether the system is allowing homes to get paid for poor quality services that may be harming residents, investigators said, and recommended that the Centers for Medicare & Medicaid Services tie payments to homes' abilities to meet basic care requirements. The report also recommended that the agency strengthen its regulations and ramp up its oversight. The review did not name individual homes, nor did it estimate the number of patients who had been mistreated, but instead looked at the overall number of stays in which problems arose.

In response, the agency agreed that it should consider tying Medicare reimbursements to homes' provision of good care. CMS also said in written comments that it is reviewing its own regulations to improve enforcement at the homes.

"Medicare has made significant changes to the way we pay providers thanks to the health care law, to reward better quality care," Medicare spokesman Brian Cook said in a statement to AP. "We are taking steps to make sure these facilities have the resources to improve the quality of their care, and make sure Medicare is paying for the quality of care that beneficiaries are entitled to."

CMS hires state-level agencies to survey the homes and make sure they are complying with federal law, and can require correction plans, deny payment or end a contract with a home if major deficiencies come to light. The agency also said it would follow up on potential enforcement at the homes featured in the report.

Greg Crist, a Washington-based spokeswoman for the American Health Care Association, which represents the largest share of skilled nursing facilities nationwide, said overall nursing home operators are well regulated and follow federal guidelines but added that he could not fully comment on the report's conclusions without having had the chance to read it.

"Our members begin every treatment with the individual's personal health needs at the forefront. This is a hands-on process, involving doctors and even family members in an effort to enhance the health outcome of the patient," Crist said.

Virginia Fichera, who has relatives in two nursing homes in New York, said she would welcome a greater push for accountability at skilled nursing facilities.

"Once you're in a nursing home, if things don't go right, you're really a prisoner," said Fichera, a retired professor in Sterling, NY. "As a concerned relative, you just want to know the care is good, and if there are problems, why they are happening and when they'll be fixed."

Once residents are ready to go back home or transfer to another facility, federal law also requires that the homes write special plans to make sure patients are safely discharged.

Investigators found the homes didn't always do what was needed to ensure a smooth transition.

In nearly one-third of cases, facilities also did not provide enough information when the patient moved to another setting, the report found.

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On the Web:

The OIG report: http://1.usa.gov/VaztQm

The Medicare nursing home database: http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1&AspxAutoDetectCookieSupport=1

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Follow Garance Burke on Twitter at —http://twitter.com/garanceburke.

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Eric Garcetti showed political savvy during busy student years

Fourth in a series of articles focusing on key periods in the lives of the mayoral hopefuls.

Ben Jealous still recalls walking into a Columbia University meeting of a new group called Black Men for Anita Hill and seeing a half-Jewish, half-Mexican kid from Los Angeles leading the discussion.

"What's he doing here?" he asked the professor who organized the meeting.

"Honestly brother," the teacher replied, "he's the only one here I'm certain will really work hard."

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It was Jealous' first exposure to Eric Garcetti, a committed young progressive known on campus for gliding between different worlds and liberal causes. As a political science major at Columbia, Garcetti patched plaster and painted walls in low-income apartments in Harlem while also serving as the president of an exclusive literary society known for its wealthy membership. He led a men's discussion group on gender and sexuality, ran successfully for student government, and wrote and performed in musicals.

His busy student years offered hints of the future political persona that would later help him win a Los Angeles City Council seat and emerge as a leading candidate for mayor. As he pursued countless progressive causes — improved race relations in New York City, democracy in Burma and human rights in Ethiopia — Garcetti also exhibited a careful stewardship of his image and a desire to get along with everyone.

Some of his critics complain that he is confrontation averse, and say his chameleon-like abilities are political. Others complain that he has lost touch with his activist roots, citing his recent advocacy for a plan to allow taller and bigger buildings in Hollywood despite strong opposition from some community members.

But Jealous, who went on to study with Garcetti at Oxford, where they were both Rhodes scholars, remembers his classmate as "authentically committed" to social justice and naturally at ease in different settings. That was a valuable trait in early 1990s New York City, when tensions between whites and blacks were high, said Jealous, who is now the president of the National Assn. for the Advancement of Colored People. Against a backdrop of racial violence, including the stabbing of the Rev. Al Sharpton in Brooklyn in 1991, "there was an urgent need to build bridges," he said.

On Columbia's campus, Garcetti pushed to involve more men in Take Back the Night protests against sexual violence and tracked hate crimes as president of the National Student Coalition Against Harassment. He also worked against homelessness and founded the Columbia Urban Experience, a program that exposes incoming freshmen to city life through volunteerism.

Judith Russell, a Columbia professor who taught Garcetti in a yearlong urban politics course, remembers him as a skilled organizer. "Eric was one of the best people I've ever met at getting people to agree," she said.

He was also ambitious. Russell says she wrote countless recommendation letters for Garcetti, who was always applying for some new opportunity. "For most people I have a file or two. For Eric I have a folder," she said.

Even as a student, Garcetti went to great lengths to guard his image and public reputation. In a 1991 letter to a campus newspaper, a 20-year-old Garcetti sought a retraction of a quote that he acknowledged was accurate. A reporter wrote that Garcetti called owners of a store that declined to participate in a Columbia-sponsored can recycling program "assholes." Garcetti said the comment was off the record.

"I would ask, then, if you would retract the quote, not because of the morality of my position, rather the ethics of the quoting," he wrote.

That self-awareness came partly from being raised in a politically active family. Back in Los Angeles, his father was mounting a successful campaign for county district attorney. His mother, the daughter of a wealthy clothier, ran a community foundation. Her father, who had been President Lyndon B. Johnson's tailor, made headlines in the 1960s when he took out a full-page ad in the New York Times calling on Johnson to exit the Vietnam War.

Garcetti's family wealth allowed him to carry on the legacy of political activism. While attending L.A.'s exclusive Harvard School for Boys, he traveled to Ethiopia to deliver medical supplies. In college, while other students worked at summer jobs, he traveled twice to Burma to teach democracy to leaders of the resistance movement.

In 1993, after receiving a master's degree from Columbia's School of International and Public Affairs, Garcetti departed for Oxford. There he met Cory Booker, a fellow Rhodes scholar who is now the mayor of Newark, N.J., and a likely candidate for the U.S. Senate. Garcetti, Booker said, "was one of those guys who would be in the pub at midnight talking passionately about making a better world."

In England, Garcetti worked with Amnesty International and also met his future wife, Amy Wakeland, another Rhodes scholar with activist leanings. Garcetti remembers being impressed when Wakeland missed President Clinton's visit to the Rhodes House at Oxford because she was on the streets protesting tuition hikes. Her worldview aligned with his, he told friends.

In his second year at Oxford, Garcetti persuaded student leaders to join him in a hunger strike after the passage of Proposition 187, the 1994 California ballot measure that denied immigrants access to state healthcare and schools.

Looking back, he sees the hunger strike as a bit of youthful folly. "We were young," Garcetti said. "Was a fast an ocean away going to overturn 187? No. But in my book, whether it's me in Los Angeles seeing an injustice across an ocean or vice versa, you have to stand up and be heard."

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India Ink: ‘Hole in the Wall’ Wins Indian Educator $1 Million TED Prize

Sugata Mitra, an Indian education innovator, was awarded the first $1 million TED Prize for what the global organization called his “innovative and bold efforts towards advancing learning for children.”

“Sugata and his colleagues carried out experiments for over 13 years on the nature of self-organized learning, its extent, how it works and the role of adults in encouraging it,” said TED, which announced the award at its influential annual conference of ideas in Long Beach, California, on Tuesday.

Mr. Mitra, along with his colleagues, dug a hole in a wall bordering a slum in New Delhi in 1999, installed a computer connected to the Internet and left it there, to demonstrate how kids can learn almost anything by themselves. He has spoken frequently on the need to improve the way children are educated.

Mr. Mitra said in a statement posted on the TED Web site that he would use the prize money to build the “School in the Cloud,” a learning lab in India, where children can engage with information and mentors online.

“My wish is to help design the future of learning by supporting children all over the world to tap into their innate sense of wonder and work together,” he said.

“Our current definition of education is to produce individuals who can fit into a bureaucratic machine,” Mr. Mitra told Forbes. “The result is a society that creates identical factory workers. The day of the factory is done.”

He has also underscored the power of cloud computing to revamp the way children learn.

In Mr. Mitra’s closing remarks while accepting the TED Prize, he shared an anecdote: “A little girl was following me around. I said, ‘I want to give a computer to everyone,’” recalls Mitra. “She reached out her hand and she said to me, ‘Get on with it.’”

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Titanic to Sail Again - But Will You Get Onboard?

By Stephen M. Silverman

02/27/2013 at 09:15 AM EST

Leonardo DiCaprio and Kate Winslet, in Titanic

Paramount Pictures/AP

It's the biggest Oscar winner of all time, but it's also a code word for disaster: Titanic.

Now, an Australian billionaire plans to recreate the legendary ship, and charge $1 million for a first-class cabin when his replica Titanic II re-traces the original 1912 route of the great ship that went down.

Once the new ship is built in China, its maiden voyage is scheduled for late 2016 and will hopefully go the full distance from England's Southampton to New York's West Side.

Its furnishings, said its financier Clive Palmer, will include a Turkish bath (just like on the original) and the ornate grand staircase which Leonardo DiCaprio and Kate Winslet descended in the 1997 James Cameron movie.

It will also have some things the original didn't: air-conditioning and enough lifeboats.

But will it be "unsinkable?" Unthinkable, Palmer said at a press conference in New York Tuesday.

"Anything will sink if you put a hole in it," he said. "I think it would be very cavalier to say it."

The ship will have three separate classes – with no mingling among them, like in the movie – and offer period costumes to its passengers.

Does that sound like fun to you?

The great ship, Titanic (1997)

Everett

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Vt. lye victim gets new face at Boston hospital

BOSTON (AP) — A Vermont woman whose face was disfigured in a lye attack has received a face transplant.

Doctors at Boston's Brigham and Women's Hospital say 44-year-old Carmen Blandin Tarleton underwent the surgery earlier this month.

A team worked 15 hours to transplant the facial skin, including the neck, nose, lips, facial muscles, arteries and nerves.

The 44-year-old Tarleton, of Thetford, Vt., was attacked by her former husband in 2007. He doused her with industrial strength lye. She suffered chemical burns over 80 percent of her body. The mother of two wrote a book about her experience that describes her recovery.

It was the fifth face transplant at the Boston hospital.

Physicians are planning to discuss the case Wednesday at the hospital.

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Imperial County betting its future on renewable energy

Situated in the southeastern corner of California, bordering Arizona and Mexico, Imperial County has long depended on agriculture and cash crops that grew from the good earth.

But lately the region — which carries the dubious distinction of having the state's highest unemployment rate at 25.5% — is betting its future on a different kind of farm: green energy.

Spurred by a state mandate that requires utilities to get a third of their electricity from green sources by 2020, renewable energy companies are leasing or buying thousands of acres in Imperial County to convert to energy farms providing power for coastal cities — bringing an estimated 6,000 building jobs and billions in construction activity to the county.

Although renewable energy projects are sprouting up across the Golden State, no county needs them as much as Imperial, which has consistently ranked as the worst-performing region of California even in boom times.

The prospect of a construction boom has excited residents hungry for work. But some farmers and Native American tribes are crying foul, angry that the new projects are encroaching on land that they claim has cultural value or should be devoted to crops.

Solar, wind and geothermal projects are popping up on farms that once grew wheat, alfalfa and sugar beets. County officials say the normally hardscrabble region is benefiting from vast tracts of affordable land and lots of sunshine, the one resource the region can almost always count on.

"It's sunny 365 days of the year, damn near," boasted Mike Kelley, chairman of the county's Board of Supervisors. "Renewable energy is going to give Imperial County a shot in the arm."

Local advocates are betting that a "green rush" will lift a county that has struggled with economic upheaval. The Bureau of Labor Statistics just ranked El Centro as the second-worst metro area for job hunters, after Yuma, Ariz. Its unemployment rate fluctuated between 25% and 33% from 2010 and 2012.

Two of the county's top five employers are the Calipatria and Centinela state prisons. The agriculture sector shed jobs as farmers moved to automation and switched to less labor-intensive crops. Construction work vanished when El Centro, the county's biggest city, was hit hard by the housing crisis. Long-standing businesses such as a food processing plant moved elsewhere, taking away hundreds of jobs.

But with green energy companies scrambling to build solar installations and wind farms throughout the county, some residents are convinced that Imperial's fortunes will soon be looking up.

Tenaska Solar Ventures plans to break ground this year on its second project in the county after nearing completion on its first site, known as the Imperial Solar Energy Center South, on nearly 1,000 acres near El Centro.

The company came to the region both for its "abundant sunshine" and also proximity to the Sunrise Powerlink, a power transmission line completed last year that connects Imperial and San Diego counties, said Bob Ramaekers, Tenaska's vice president of development.

More than 500 construction workers have been hired to work on Tenaska Imperial South, with 70% coming from the local community, he said. A job fair held last year drew about 1,200 applicants. The second project will generate as many as 300 construction jobs, with priority given to local hires.

"One of the advantages of solar projects is they are not really high-tech. Anyone who has worked at all in the construction business can work in a solar facility," said Andy Horne, deputy executive officer of the county's natural resources department. "It's like a big erector set — you bolt these things together and ba-da-bing, you have a solar project."

The lure of a steady, well-paid job is what persuaded Victor Santana, 27, to start training as a journeyman electrician two years ago. He had studied film in college and hoped to make movies, but ended up working a series of odd jobs after the economic downturn — driving tractors, operating hay presses, selling vacuum cleaners. Even a video-editing gig he eventually found paid minimum wage,

"Things had dried up. There was only field work, or fast food, or working at the local mall," the El Centro resident said.

Santana finally decided to switch careers after hearing the pitch from green energy companies trickling into town. Now he earns about $21 an hour with regular raises every six months, and the prospect of steady work for another seven to 10 years just from the stream of solar and wind projects. "I feel a lot more secure than I did," he said.

Green energy may help Imperial hold onto its young people, who often try to land a government job or leave the county altogether in search of better-paying jobs elsewhere. Calipatria Unified School District is launching a vocational program this fall to prepare high school graduates for jobs in renewable energy. San Diego State is building a power plant simulator at its Brawley campus.

"With the advent of renewable energy, we are seeing a different kind of industrial base," said Mike Sabath, associate dean of academic affairs at San Diego State's Imperial Valley campus. "Hopefully that will provide opportunities to develop more job stability in the region than what we have enjoyed."

But construction has raised the hackles of some locals. There are farmers wringing their hands over fertile land snapped up by energy companies; they worry that a way of life is being edged out by corporations eager to cash in on the modern gold rush.

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The Lede: Comedian’s Blog Morphs Into Major Political Force in Italy

Last Updated, Tuesday, 10:08 a.m. Although an aide to the former prime minister Silvio Berlusconi demanded a recount late Monday, after his center-right coalition appeared to lose the battle for the Italian Parliament’s lower house to the main center-left coalition by less than 0.4 percent, a look at the raw vote totals reveals a sharp decline in support for him. According to the provisional count, Mr. Berlusconi’s party got about six million fewer votes than in 2008, slipping from first place all the way to third.

As my colleague Rachel Donadio explains, though, that did not spell a triumph for Mr. Berlusconi’s traditional rivals, the center-left Democratic Party, which lost nearly four million votes, because more than eight million Italians voted for the Five Star Movement, a party that emerged, fully formed, from the comedian Beppe Grillo’s popular blog. At the end of counting late Monday, Mr. Grillo’s party had more votes than any other in the lower house election and the second-most votes for Italy’s Senate.

#TsunamiTour CAMPIONE 94.6% #M5S PRIMO ALLA CAMERA 25.9% http://t.co/n4jF7UGMz5 Spoglio in diretta http://t.co/GmlPpkhvVC

— Francesco Manna (@FrancescoLamana) 25 Feb 13

While Mr. Grillo’s mass movement, which drew support from disenchanted voters on the left and the right, did not run as part of either main coalition and so will not lead Italy’s next government, the scale of the new party’s turnout, organized largely through the Internet and vast rallies, stunned observers.

In first ever parliamentary election, 5-Star Movement got more votes than any other party in lower house, 2nd most in Senate #italyreuters

— Naomi O’Leary (@NaomiOhReally) 26 Feb 13

In an update to nearly 1 million followers on Twitter, Mr. Grillo hailed the result, telling supporters, “We have become the leading force in absolute terms after just three and a bit years, without money, without ever having accepted the reimbursement of expenses.”

Siamo diventati la prima forza in assoluta in tre anni, senza soldi, senza aver mai accettato un rimborso:http://t.co/NOWtOXMHWW

— Beppe Grillo (@beppe_grillo) 26 Feb 13

According to a translation on the English-language version of his blog, Mr. Grillo told supporters in a telephone interview streamed live on YouTube late Monday:

This adventure that we’re having is fantastic. First of all I just want to thank those extraordinary young people that made it possible to find the stages, the lights, the security services, the people that put us up in their homes, that have helped us with the camper. This is the difference between this grassroots movement and “the others”. “The others” are paid and are carried around in buses with flags. We are all volunteers. This is why so many thanks are needed.

Given that neither of the main coalitions will be able to command a majority, Mr. Grillo said, they will most likely have to combine to form an interim government until there can be fresh election. In the meantime, he added:

We are the obstacle. They can no longer succeed against us. Let them resign themselves to that. They’ll be able to keep going for 7 or 8 months and they’ll produce a disaster but we’ll try and keep them under control. We’ll start to do what we’ve always said – our stars: water in public hands, schools in public hands, public health service. If they follow us they follow us. If they don’t, the battle will be very harsh for them, very harsh.

Since the term of Italy’s president is also at an end, one of the first challenges facing Italy’s fractured new Parliament will be to elect a successor. In an update posted on Twitter on Tuesday, Mr. Grillo declared that his movement would decide who to support in an online ballot. Signalling change, he added, “Spring is coming.”

Il candidato presidente della Repubblica del M5S sarà deciso dagli iscritti al M5S attraverso un voto on line. Sta arrivando la primavera

— Beppe Grillo (@beppe_grillo) 26 Feb 13

While the surge in support for Mr. Grillo’s party was described as a shock in many parts of the Italian and international media, there were clear signs of the Five Star Movement’s growing popularity in the series of late rallies Mr. Grillo called his #TsunamiTour on Twitter, culminating in a final campaign appearance attended by an estimated 800,000 in Rome’s Piazza San Giovanni.

Images of recent mass rallies for Beppe Grillo’s Five Star Movement.

800k in piazza, 150k in streaming in contemporanea, 120 piazza collegate. LI MANDIAMO TUTTI A CASA! #tsunamitour http://t.co/Buul4a7NGn

— Beppe Grillo (@beppe_grillo) 22 Feb 13

One byproduct of Mr. Grillo’s success could be fresh elections, because the center-left coalition led by the Democratic Party, which spurned him as a potential candidate four years ago, is now unable to command a majority in the upper house and so may not be able to form a government. In a Twitter update on Tuesday, Mr. Grillo ruled out joining a governing coalition.

In 2009 Grillo wanted to stand in PD primaries. He was told: “create your own party and see how many votes you get”. He did. #elezioni2013

— Alberto Nardelli (@AlbertoNardelli) 26 Feb 13

As the Guardian correspondent John Hooper noted, Mr. Grillo’s ability to tap into popular outrage over corruption in Italy, owes at least as much to his background in economics as to his comedian’s sharp tongue:

Grillo was born 64 years ago in Genoa and studied commercial economics. He might have ended up a provincial accountant.

His studies are the key to why he has such an acute perception of the many scandals in Italy in which politics and finance overlap, like the one enveloped its oldest bank, Monte dei Paschi di Siena, during the campaign. Grillo can read company accounts in a way few journalists and politicians can. The year before the Italian food giant, Parmalat, collapsed in 2003, Grillo forecast on television what was to be Europe’s biggest bankruptcy….

He disappeared from the state-owned RAI in 1993. Its rival network, Mediaset, had the odd satire programme, but none was allowed seriously to target the network’s proprietor, Silvio Berlusconi.

Grillo’s exclusion from television is crucial to understanding the man and his success. It added yet more anger to the ranting monologues that had become his speciality. And it forced him to turn to what was then a medium decidedly outside the mainstream, founding a blog that soon became a samizdat for the young, frustrated, indignant and internet-savvy.

As my colleagues Ian Fisher and Rob Harris explained in an article and a video report on Mr. Grillo in 2007, he first rallied popular support that year with his “V-Day,” based on the deep-seated desire of many Italians to dismiss their entire political class with an obscene phrase that starts with that letter in Italian.

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Jennifer Lawrence Dyes Her Hair Jet Black

By Tim Nudd

02/26/2013 at 09:15 AM EST

Jennifer Lawrence, blonde (left) and brunette

Jason Merritt/Getty; AKM-GSI

Oscar's golden girl, Jennifer Lawrence, has gone brunette – almost jet black, in fact!

The day after winning Best Actress for her role in Silver Linings Playbook, Lawrence, 22, was right back at work – emerging from a Beverly Hills salon with newly dyed black hair as she prepares to play Katniss Everdeen in reshoots for the next Hunger Games movie.

The actress was dressed mostly in black, too – with a black cardigan and black skirt to go along with a gray T-shirt.

It was quite a contrast to her dazzling look on Sunday, with her golden hair and Dior Haute Couture dress with Chopard jewels, a Roger Vivier clutch and Brian Atwood shoes.

One thing she was still sporting, though, was her glowing smile.

Reshoots for The Hunger Games: Catching Fire are expected to begin as soon as this week, reportedly in Hawaii. The movie is due in theaters at Thanksgiving.

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Koop, who transformed surgeon general post, dies

With his striking beard and starched uniform, former Surgeon General Dr. C. Everett Koop became one of the most recognizable figures of the Reagan era — and one of the most unexpectedly enduring.

His nomination in 1981 met a wall of opposition from women's groups and liberal politicians, who complained President Ronald Reagan selected Koop, a pediatric surgeon and evangelical Christian from Philadelphia, only because of his conservative views, especially his staunch opposition to abortion.

Soon, though, he was a hero to AIDS activists, who chanted "Koop, Koop" at his appearances but booed other officials. And when he left his post in 1989, he left behind a landscape where AIDS was a top research and educational priority, smoking was considered a public health hazard, and access to abortion remained largely intact.

Koop, who turned his once-obscure post into a bully pulpit for seven years during the Reagan and George H.W. Bush administrations and who surprised both ends of the political spectrum by setting aside his conservative personal views on issues such as homosexuality and abortion to keep his focus sharply medical, died Monday at his home in Hanover, N.H. He was 96.

An assistant at Koop's Dartmouth College institute, Susan Wills, confirmed his death but didn't disclose its cause.

Dr. Richard Carmona, who served as surgeon general a decade ago under President George W. Bush, said Koop was a mentor to him and preached the importance of staying true to the science even if it made politicians uncomfortable.

"He set the bar high for all who followed in his footsteps," Carmona said.

Although the surgeon general has no real authority to set government policy, Koop described himself as "the health conscience of the country" and said modestly just before leaving his post that "my only influence was through moral suasion."

A former pipe smoker, Koop carried out a crusade to end smoking in the United States; his goal had been to do so by 2000. He said cigarettes were as addictive as heroin and cocaine. And he shocked his conservative supporters when he endorsed condoms and sex education to stop the spread of AIDS.

Chris Collins, a vice president of amFAR, the Foundation for AIDS Research, said many people don't realize what an important role Koop played in the beginning of the AIDS epidemic.

"At the time, he really changed the national conversation, and he showed real courage in pursuing the duties of his job," Collins said.

Even after leaving office, Koop continued to promote public health causes, from preventing childhood accidents to better training for doctors.

"I will use the written word, the spoken word and whatever I can in the electronic media to deliver health messages to this country as long as people will listen," he promised.

In 1996, he rapped Republican presidential hopeful Bob Dole for suggesting that tobacco was not invariably addictive, saying Dole's comments "either exposed his abysmal lack of knowledge of nicotine addiction or his blind support of the tobacco industry."

Although Koop eventually won wide respect with his blend of old-fashioned values, pragmatism and empathy, his nomination met staunch opposition.

Foes noted that Koop traveled the country in 1979 and 1980 giving speeches that predicted a progression "from liberalized abortion to infanticide to passive euthanasia to active euthanasia, indeed to the very beginnings of the political climate that led to Auschwitz, Dachau and Belsen."

But Koop, a devout Presbyterian, was confirmed after he told a Senate panel he would not use the surgeon general's post to promote his religious ideology. He kept his word.

In 1986, he issued a frank report on AIDS, urging the use of condoms for "safe sex" and advocating sex education as early as third grade.

He also maneuvered around uncooperative Reagan administration officials in 1988 to send an educational AIDS pamphlet to more than 100 million U.S. households, the largest public health mailing ever.

Koop personally opposed homosexuality and believed sex should be saved for marriage. But he insisted that Americans, especially young people, must not die because they were deprived of explicit information about how HIV was transmitted.

Koop further angered conservatives by refusing to issue a report requested by the Reagan White House, saying he could not find enough scientific evidence to determine whether abortion has harmful psychological effects on women.

Koop maintained his personal opposition to abortion, however. After he left office, he told medical students it violated their Hippocratic oath. In 2009, he wrote to Senate Majority Leader Harry Reid, urging that health care legislation include a provision to ensure doctors and medical students would not be forced to perform abortions. The letter briefly set off a security scare because it was hand delivered.

Koop served as chairman of the National Safe Kids Campaign and as an adviser to President Bill Clinton's health care reform plan.

At a congressional hearing in 2007, Koop spoke about political pressure on the surgeon general post. He said Reagan was pressed to fire him every day, but Reagan would not interfere.

Koop, worried that medicine had lost old-fashioned caring and personal relationships between doctors and patients, opened his institute at Dartmouth to teach medical students basic values and ethics. He also was a part-owner of a short-lived venture, drkoop.com, to provide consumer health care information via the Internet.

Koop was born in the New York City borough of Brooklyn, the only son of a Manhattan banker and the nephew of a doctor. He said by age 5 he knew he wanted to be a surgeon and at age 13 he practiced his skills on neighborhood cats.

He attended Dartmouth, where he received the nickname Chick, short for "chicken Koop." It stuck for life.

Koop received his medical degree at Cornell Medical College, choosing pediatric surgery because so few surgeons practiced it.

In 1938, he married Elizabeth Flanagan, the daughter of a Connecticut doctor. They had four children, one of whom died in a mountain climbing accident when he was 20.

Koop was appointed surgeon-in-chief at Children's Hospital in Philadelphia and served as a professor at the University of Pennsylvania School of Medicine.

He pioneered surgery on newborns and successfully separated three sets of conjoined twins. He won national acclaim by reconstructing the chest of a baby born with the heart outside the body.

Although raised as a Baptist, he was drawn to a Presbyterian church near the hospital, where he developed an abiding faith. He began praying at the bedside of his young patients — ignoring the snickers of some of his colleagues.

Koop's wife died in 2007, and he married Cora Hogue in 2010.

He was by far the best-known surgeon general and for decades afterward was still a recognized personality.

"I was walking down the street with him one time" about five years ago, recalled Dr. George Wohlreich, director of the College of Physicians of Philadelphia, a medical society with which Koop had longstanding ties. "People were yelling out, 'There goes Dr. Koop!' You'd have thought he was a rock star."

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Ring reported from Montpelier, Vt. Cass reported from Washington. AP Medical Writers Lauran Neergaard in Washington and Mike Stobbe in New York contributed to this report.

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Does Eric Garcetti keep his word? Accounts vary

Santiago Perez and his neighbors went straight to Councilman Eric Garcetti when they heard that a developer planned to build a 62-unit housing and retail development on their quiet street in Echo Park.

Worried that the four-story complex would tower over homes and bring excess traffic, the group emerged from their meeting at Los Angeles City Hall feeling relieved. "He told us that, yes, he's with us and he will do everything possible to reject the plan," Perez said.

But months later in front of the citywide Planning Commission, a Garcetti representative offered the lawmaker's tacit support for the project, saying it was "designed well" and would bring needed jobs and housing to the area.

Perez and his neighbors felt blindsided. "He said one thing and then he did another," Perez said. One of his neighbors fired off an angry message via Twitter: "Eric Garcetti went back on his word."

If Garcetti succeeds in his bid to become L.A.'s next mayor, he will face new pressure to take decisive action on hotly contested issues. A number of colleagues and constituents say he has not always been a steadfast ally and decision maker.

Another mayoral front runner, Wendy Greuel, alluded to that allegation in a recent appearance before city workers, saying they need someone who will "be true to their word."

Garcetti insists he never wavers from a promise. In nearly 12 years in office, he has made decisions that have upset some people, he acknowledged. But the vast majority of people he has worked with have had positive experiences, he said.

He said that he never committed to fighting the Echo Park development and that he "reserves the right" to take his time forming a position on an issue. "I listen to a lot of people to make sure I'm as well-informed as possible up until the last hour," he said.

Councilman Bernard C. Parks, who has served alongside Garcetti for more than a decade, said Garcetti too often tests the political winds before taking a stand. Parks, who is backing Councilwoman Jan Perry's bid for mayor, alleges that Garcetti misled him last year by voting for a controversial redistricting plan after indicating he opposed it. Garcetti also undermined the city's efforts to hold down costs of employee union contracts, Parks said.

"I think he doesn't want to make an enemy of anyone," Parks said.

Garcetti said that he never told Parks he would oppose the redistricting plan and that the tough stance he took with the unions is "the reason I don't have [them] lining up behind me."

Questions of Garcetti's reliability arose for Marc Galucci, who went to the councilman for support in turning his Echo Park cafe into a restaurant serving beer and wine.

Galucci assembled neighbors to back his application for a liquor license for Fix Coffee, but parents of some children at a nearby school opposed it.

Galucci said Garcetti told him that he would remain neutral but offered suggestions on how to gain community support. Then, at 10 p.m. the night before the liquor license hearing, a Garcetti representative phoned. "Tomorrow at the hearing we're going to oppose this," she said.

"I was just flabbergasted," said Galucci. He later learned that Monica Garcia, president of the Board of the Los Angeles Unified School District, had asked Garcetti to oppose the request.

In the end, Galucci got the license, but he said the situation left him with a bad taste.

Garcetti acknowledged that the issue had been "a contentious one," but he said he had not pledged to remain neutral. He said that he initially liked the idea of a liquor permit for Fix but that community opposition "continued to grow and grow."

Former Councilwoman Jackie Goldberg, who has endorsed Garcetti, said that it's important to be flexible but that avoiding a strong stand can leave the wrong impression. "I do know that he is a person who tries to make people happy, and when you do that, people hear what they want to hear," she said.

On the campaign trail, Garcetti often touts his strengths as a consensus builder. Some current and former colleagues say his desire to find a compromise can be a weakness when consensus isn't possible.

Former City Councilman Greig Smith recalled a 2010 struggle in which the Department of Water and Power and Mayor Antonio Villaraigosa sought to raise rates to a level the council thought inappropriate. On the day of the vote, Garcetti and Perry appeared before the DWP commission to say the council would not support the plan.

When Garcetti returned to the council for a late-night hearing, he urged his colleagues to rethink the rate hike, according to Smith, who is supporting Perry. Smith said that before Garcetti had a chance to persuade his colleagues to reconsider the hike, Smith pushed through a vote to table it.

Garcetti disputes the account, saying he did not seek reconsideration.

In the wake of the DWP fight, Garcetti backed a successful ballot measure to create the Office of Public Accountability intended to scrutinize the utility. Jack Humphreville, an activist who has long complained about high salaries at the city-owned utility, said Garcetti's office at first seemed to support a multimillion-dollar budget for the office and broad powers for a ratepayer advocate.

Garcetti later allowed the ballot measure to be "neutered" after pressure from the utility workers union, Humphreville said. The ratepayer advocate's powers were reduced and its granted funding was cut.

"Eric agreed to all this stuff, and then he started backpedaling on us," Humphreville said.

Garcetti disagreed, saying the office has substantial powers.

Nick Patsaouras, a former DWP board member, said that he also was disappointed by the final measure but that Garcetti's concessions probably kept it from "being killed" entirely by labor advocates.

"I think Eric did well, considering," he said.

kate.linthicum@latimes.com

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