Coming Wednesday: "In India, verdant terrain conceals clues to a fatal kidney disease"

Meridian is not alone under the Justice Department magnifying glass. In a somewhat similar case in Tennessee,  DOJ says the Juvenile Court of Memphis and Shelby County has failed both to inform children of the charges against them and to make sure they understand what their legal rights are ahead of questioning. Like Meridian, the juvenile court is also accused of failing to hold timely hearings.

Worries about a school-to-prison pipeline have grown in recent years, but there are different ways to define the issue, said Jim Freeman, senior attorney at Advancement Project, a nonprofit legal action group that fights racial injustice.

“How I like to define it,” Freeman said, “is the use of policies and practices that increase the likelihood that young people become incarcerated.”

That includes at-school arrests for minor behavioral incidents, as well as what he calls more indirect actions, like suspensions, expulsions or references to juvenile court or alternative schools.

Such practices have grown in the last 10 to 15 years, he said. “It really started out mostly in very low income communities of color, the schools in those districts. It’s expanded pretty dramatically beyond that.”

In a high-profile Delaware case in 2009, a six-year-old was almost suspended for 45 days for having his Cub Scout knife at school. The school board intervened to cut that to three to five days.

The combination of zero-tolerance school rules, themselves fueled by safety fears, and the kind of high-stakes testing required by the federal government “create some of these dynamics,” Freeman contended.

Mississippi was under the high-stakes testing regime of the federal No Child Left Behind law until it won a waiver in July 2012.

Low-performing schools are under such pressure to meet testing benchmarks that some neglect the education of some struggling students, even pushing them out of school, reports suggest. Data compiled in a 2010 Advancement Project report finds that in several U.S. states, there was a link between the adoption of high-stakes testing and increased use of suspensions and expulsions.

“Race has certainly played a role in where we have elected to implement these policies and practices,” Freeman added, “I think the data is pretty clear.”

By mid-October Meridian, Miss. could land in court because of the federal investigators’ allegations. The DOJ threatened to file suit by then if the city and county and state agencies don’t start “meaningful negotiations” with the federal agency.

Politicians who are promising to repeal ObamaCare won’t find any evidence in the Kaiser Family Foundation’s analysis of health insurance costs that the law has caused premiums to skyrocket, as many of those politicians have contended.

On the contrary, premiums have increased on average only 4 percent over the past year, the lowest rate of increase in years, according to Kaiser’s 2012 Employer Health Benefits Survey, which was released last week. Double-digit premium increases were once the norm, especially during the George W. Bush administration. Premiums increased 10 percent in 2004 and 13 percent in 2003.

So the good news is that premiums increased only 4 percent. The not so good news is that, because of all those past double-digit increases, the average premium for employer-sponsored health coverage has reached a record high of $15,745. And because employers have been shifting more and more of the cost of coverage to workers, employees are now paying, on average, nearly 30 percent of that total, much more than they used to. The hike in worker contributions has far outstripped the overall rise in premiums.    

A study published last year in Health Affairs found that the gains in wages U.S. workers made over the past decade were more than wiped out by increases in the cost of health care and health insurance. Kaiser’s annual surveys document that: since 2002, premiums have increased 97 percent, which is three times as fast as wages (33 percent) and inflation (28 percent).

That’s not all the bad news, unfortunately. More Americans are now enrolled in high deductible plans, because that’s frequently all their employers are offering. Kaiser found that the percentage of workers enrolled in plans with an annual deductible of $1,000 or more has increased from 10 percent in 2006 to 34 percent in 2012. The growth has been even greater for employees of small firms.

It gets worse. Many workers are now longing for the good old days of having to pay “just” $1,000 in deductibles. Fourteen percent of workers are now in plans with deductibles of $2,000 or more, compared to 3 percent in 2006.

And those numbers are just for single coverage. Families are getting hit much harder. Workers enrolled in high deductible plans are now facing annual family deductibles of almost $4,000 on average.  Many have much, much higher deductibles.

As troubling as those numbers are, it is all too easy when we look at them for our eyes to glaze over and to forget that we are talking about real people. But because of these trends, increasing numbers of us are finding it impossible to get the care we need, even if we have insurance.

A couple of days after the Kaiser study was released, Consumer Reports released a study of its own showing that over the past year, 45 percent of adults under the age of 65 skipped getting a prescription and 63 percent canceled a doctor’s appointment, even though they were sick, to save money. Many others decided not to get a doctor-ordered test or undergo a needed medical procedure.

An untold number of Americans undoubtedly did go forward with a procedure their doctors said was necessary to save their lives and, as a consequence, are now facing bankruptcy.

Like the mother of a friend of mine whose doctor discovered through expensive testing last year that she had a pancreatic tumor. Thinking she had adequate coverage through her employer, Federal Express, the woman agreed to surgery. Fortunately, it was successful.  Her doctors say she is cancer free, at least for now. Unfortunately, she hadn’t paid much attention to how much the surgery would cost because of her switch a few years ago into a high-deductible plan.

A single mother who, according to her daughter, lives paycheck to paycheck, she was in shock as the medical bills started pouring in. When they reached $6,000, which she was obligated to pay, she decided she had no choice but to file for bankruptcy.

For political candidates who make hundreds of thousands of  dollars a year, $6,000 is pocket change. For most Americans, however, suddenly owing that much money can mean financial ruin.  If ObamaCare goes forward, beginning in 2014, the law will set a cap on out-of-pocket spending. That  cap will still be too high to keep some of us out of bankruptcy court. If the law is repealed, however, many more of us undoubtedly will wind up there.

Tea-party aligned super PAC FreedomWorks for America released 11 new ads over the weekend targeting hotly contested U.S. Senate races in Florida, Arizona, Ohio, Indiana and Virginia:

• “The American Dream” supports the U.S. Senate run of Rep. Connie Mack, R-Fla., who is challenging Democratic Sen. Bill Nelson;
• “Failing Florida” opposes Nelson;
• “Handpicked by Obama” opposes Democrat Richard Carmona, who served as President George W. Bush’s surgeon general and is now running for U.S. Senate in Arizona against Rep. Jeff Flake, a Republican;
• “A Proven Leader” supports Flake;
• “Dividing Ohio” and “Politics before Ohio” opposes Sen. Sherrod Brown, D-Ohio, who faces Republican Josh Mandel, the state’s treasurer;
• “Take Back America” supports Mandel;
• “Don’t Trust His Record” opposes Rep. Joe Donnelly, D-Ind., who is running for U.S. Senate against Indiana State Treasurer Richard Mourdock;
• “A Good Hoosier” supports Mourdock, who won a contested GOP primary earlier this year;
• “George Allen Stands Strong for Freedom” supports the former Republican senator’s run for U.S. Senate in Virginia;
• “You Didn’t Build That” criticizes Allen’s Democratic opponent, former Virginia Gov. Tim Kaine.

FreedomWorks for America is the super PAC component of the former Republican House Majority Leader Dick Armey’s FreedomWorks network. The super PAC supports economically conservative candidates and has helped tea party-favored candidates triumph over establishment Republican candidates in several senatorial primaries, notably Indiana and Texas, where former state Solicitor General Ted Cruz bested Lt. Gov. David Dewhurst.

The five U.S. Senate races targeted over the weekend are particularly competitive. Florida and Ohio lean Democrat and both have Democratic incumbents. Arizona and Indiana, both open seats, lean Republican. Virginia, also an open seat, is a tossup, according to The New York Times.

The U.S. Senate contests in Virginia and Ohio have drawn more outside money than almost any other Senate race, according to the Center for Responsive Politics.

Records show that more than one-third of contributions to FreedomWorks for America have come from its affiliated nonprofit, FreedomWorks Inc., which means the source of the money is unknown. (Nonprofits are generally not required to publicly report their donors.)

Ryan Hecker, the super PAC's treasurer and legal counsel, said the ads are just online for now, and the group's initial online ad buy totals about $200,000.

The super PAC has made $3.1 million in independent campaign expenditures so far, according to the Center for Responsive Politics.

FreedomWorks was also on the ground on Saturday in Ohio, where its National FreePAC Tour featured Mandel, conservative radio host Glenn Beck and FreedomWorks president Matt Kibbe. The event included grassroots training on phone banking, yard sign “blitzes” and door-to-door outreach. The tour will stop in Florida in October.

In other outside spending news:

• The Congressional Leadership Fund, a conservative super PAC backed by super donors Sheldon and Miriam Adelson and Bob Perry, reported its first independent expenditure — $558,000 in television ads opposing the re-election of Rep. Betty Sutton, D-Ohio. Sutton faces Republican Rep. Jim Renacci in Ohio’s redrawn 16th Congressional District, a tossup race.
   
• AFSCME PEOPLE, the PAC of the American Federation of State, County and Municipal Employees, reported spending $541,000 on “Didn’t Take Long,” an ad opposing Renacci in Ohio. AFSCME also spent $360,000 from its union treasury on “Gamble” and $422,000 on “A Lot to Say,” both of which oppose Rep. Denny Rehberg, R-Mont., who is running for U.S. Senate against Democratic incumbent Jon Tester.
   
• The Democratic Senatorial Campaign Committee reported spending $1.3 million on ads opposing Republican candidates for the U.S. Senate: Rehberg in Montana, Mandel in Ohio, former Gov. Tommy Thompson in Wisconsin and former wrestling executive Linda McMahon in Connecticut.
   
• The Democratic Congressional Campaign Committee reported spending $244,000 opposing Republican House candidates in five districts. The DCCC also released "Only in Washington" opposing the re-election of Rep. Ann Marie Buerkle, R-N.Y.
   
• Conservative nonprofit Crossroads GPS reported spending $5.3 million on ads opposing President Barack Obama. Additionally, its sister super PAC American Crossroads released “Skips,” which accuses Obama of absenteeism in the White House. “Mr. President, it’s time to show up for work,” the ad states. Politics365 has noted that in his first three years in office Obama took less than half the amount of vacation as his predecessor, Republican George W. Bush, who spent 180 days on vacation during his first three years in office.
   
• On Friday, pro-Democrat House Majority PAC reported spending $452,000 opposing Republican House candidates in four districts. On Saturday, it reported an additional $1.3 million in ads opposing Republicans in 10 districts.
   
• Majority PAC, a super PAC supporting Democratic candidates for U.S. Senate, reported $319,000 in ads opposing Tommy Thompson in Wisconsin, who faces Democratic Rep. Tammy Baldwin in the state’s U.S. Senate contest.
   
• The National Republican Senatorial Committee reported spending $1 million opposing Democratic Senate candidates Heidi Heitkamp in North Dakota and Jon Tester in Montana, as well as independent Angus King in Maine. The National Republican Congressional Committee reported spending $4.1 million on ads opposing Democrats in numerous House districts.
   
• The super PAC Treasure Coast Jobs Coalition reported spending $507,000 opposing Democrat Patrick Murphy, the vice president of an environmental cleanup firm, who is running for U.S. House against tea party favorite Rep. Allen West. This is the group’s only reported expenditure.
   
• SEIU COPE, the political action committee of the Service Employees International Union, reported spending $858,000 on ads opposing Republicans and supporting Democrats in House, Senate and presidential races.
   
• American Action Network, a conservative nonprofit, spent a total $416,000 on ads opposing the House runs of former Rep. Nick Nolan, D-Minn., and Democrat David Gill in Illinois. Nolan faces Republican Rep. Chip Cravaack, and Gill, a physician, faces Republican Rodney Davis, a congressional aide.

For up-to-date news on outside money in the election, follow our Source2012 Tumblr and the hashtag #Source2012 on Twitter.

KEBITHIGOLLEWA, Sri Lanka — For two decades, chronic kidney disease has been a mystery and death sentence in Sri Lanka, striking 15 percent of the residents of its north central region.

This summer, after years of secretive official research, a glimmer of scientific hope emerged. The government and World Health Organization announced in June that they identified a key cause of the disease in Sri Lanka: chronic exposure to arsenic and cadmium, likely consumed in food.

Yet in a disease that has confounded experts across continents, even potential breakthroughs come with asterisks. The new report left huge questions unanswered — including where in the country the toxins were found, how they entered the food and what foods were contaminated. The key unsolved question: the extent fertilizers and pesticides contributed to the outbreak.

In Sri Lanka’s lush northern farmlands, the mystery and the death sentences continue. Lacking firm answers from the scientific community, some victims’ best hope for survival comes through the spiritual community — and offers of kidney transplants from Buddhist monks and those they inspire to make extraordinary sacrifices for strangers.

At 21, Sampath Kumarasinghe is among the victims awaiting that miracle.

The soft-spoken farmer was diagnosed last September with kidney damage so severe it had reached its terminal phase: end stage renal disease. Healthy his entire life, he suddenly became feverish and too sick to work in the rice paddies. His mother mortgaged their land to pay for his medical care, and they began the search for a kidney donor. One day, like a vision, a man appeared in his hospital offering to donate his kidney.

“I am only thinking of ways to save my son’s life,” said Sampath’s mother, Punchirilalage Dingiri Manike. “That is what I think of day and night.”

Sampath is among the youngest victims of a broad epidemic of chronic kidney disease sweeping north central Sri Lanka. Its victims are mostly male agricultural workers who do not suffer from diabetes or hypertension, the usual causes of the illness. The government and WHO call it CKDu: chronic kidney disease of unknown etiology.

Winding path to answers

CKDu emerged in Sri Lanka’s north central farmlands, known as the “rice bowl,” in the 1990s. Physicians began noticing clusters of kidney failure in which four or five members of a single household had the disease. Rezvi Sheriff, who began practicing in the 1970s as Sri Lanka’s first nephrologist and is the unofficial dean of the country’s kidney doctors, calls it a recent phenomenon.

“In the last 20 years or so,” Sheriff said, “we have noticed it.”

Researchers developed a succession of theories to try to explain the outbreak, from cyanobacteria to fluoride to aluminum pots and pans, but none settled the debate. The conflicting alarms spread fear and confusion among villagers.

The unsolved mystery became an embarrassment to the Sri Lankan government, whose leaders take pride in the health system despite the country’s per capita GDP of roughly $5,600 — less than one-eighth that of the United States. The country points to infant and maternal mortality rates approaching those in the U.S. and Europe.

In 2008, Sri Lanka’s Health Ministry invited the World Health Organization to join a comprehensive study to unravel the disease’s roots.

For more than three years, no results were announced publicly. “Releasing information piecemeal is not the solution for the problem,” said Dr. Shanthi Mendis, Coordinator and Senior Adviser of the WHO non-communicable disease program and the lead adviser of its efforts in Sri Lanka.

Scientific alarms sounded elsewhere. A group of researchers from Sri Lanka’s University of Kelaniya released studies citing widespread arsenic contamination in drinking water, food and soil — and blaming pesticides. In June 2011, several common pesticides were found by the government to have small amounts of arsenic, and briefly banned from importation.

The Kelaniya group’s findings provoked a storm of condemnation: some scientists questioned their methods, and government officials and Sri Lanka’s agribusinesses sector accused them of harming the country.

"Loose tongues and irresponsible reporting could lead to irrevocable repercussions in the export sector and thereby adversely affect the whole economy of Sri Lanka,” Dr. Anura Wijesekara, Sri Lanka’s registrar of pesticides, wrote in a column in The Island newspaper. “One interested group has already termed this as As [arsenic] terrorism.”

Two months later, Wijesekara lifted the ban on the pesticide imports. He did so, he said in an interview, because the amount of arsenic they contained was too small to pose danger. “It’s not a big deal to have so little amount of arsenic in a pesticide because arsenic is a natural element,” Wijesekara said.

Yet in the months before the ban was lifted, the official CKDu study group was internally warning of the “imperative” of stronger regulations for “nephrotoxic agrochemicals.” A WHO meeting report from June 2011, obtained by the Center for Public Integrity, cautioned that failure to act quickly could “result in cumulative damage to the health of the people living in these areas.”

A full year later, in June 2012, the government and WHO released partial findings, concluding that exposure to low concentrations of cadmium and arsenic is a key cause of the epidemic.

“The data that we have got up until now show that it’s a combination of nephrotoxic heavy metals,” said Mendis of the WHO. “For the moment all we know is that these heavy metals have entered the food chain.”

Still, much remains unknown. The government and WHO said that lab results found small amounts of heavy metals in CKDu patients’ blood and urine, but did not specify how much. Researchers said the metals got there through the food chain — and not through the widely suspected vector of drinking water — but will not say which foods were contaminated. Mendis said a technical report to be released in late October will lay out the details.

Agneta Åkesson, a toxicologist at the Karolinska Institute who specializes in cadmium poisoning, reviewed three WHO meeting reports describing Sri Lanka’s findings through February 2012. These notes, obtained by the Center for Public Integrity and described as “administrative” by the WHO, include the results of many of the biological and environmental tests.

“Based on what’s written here, you cannot conclude anything,” Åkesson said. In the absence of any newer evidence, she said, the exposure levels described were “not enough to cause chronic kidney failure.”

The results also offered no explanation of how the heavy metals entered the food.

A leading suspect is agrochemicals, which are heavily used in the affected area’s rice paddies. Cadmium is frequently present in phosphate fertilizers and can accumulate in soil; several pesticides in Sri Lanka contain small quantities of arsenic. Some regions of the world also have low levels of arsenic that naturally occur in the environment.

The official study’s research of pesticides and fertilizers remains incomplete.

To some, the government and WHO’s reticence to release more information raises the possibility that the undisclosed evidence points toward the agrochemicals and rice crops that form the economic backbone of Sri Lanka’s long-suffering northern countryside.

Dr. Channa Jayasumana, one of the Kelaniya scientists, said that in a private meeting with his group in August the health ministry acknowledged the role of fertilizers and pesticides. A primary culprit, he said, is a fertilizer called triple superphosphate, which will be targeted for reduction in the next growing season.

“They have narrowed down the problem to heavy metals and realized the importance of fertilizers and pesticides,” Jayasumana said.

The health ministry and WHO did not respond to inquiries as to whether they had identified rice, pesticides or fertilizers such as triple superphosphate as leading sources of heavy metal exposure.

The agribusiness industry says it’s possible heavy metals contribute to the disease — but that the theory remains unproven, and dangerous levels of heavy metals could not have come from their products.

The cause could be “cadmium or arsenic,” said Rohitha Nanayakkara, Secretary of the National Agrobusiness Council. “But what we say is it can't be from pesticides, because the quantities included in pesticides are minimal.”

Meantime, the government continues to import — and farmers continue to apply — thousands of tons of agrochemicals to the fertile paddies blanketing the farmlands of Sri Lanka.

Kidneys for Strangers

As officials debate their next steps, another movement is bringing hope to Sampath and others suffering from CKDu.

As Sampath was falling ill, a man in a distant village, W.B. Ajantha, made an unusual vow. When his wife became pregnant, Ajantha promised to Buddha that he would donate his kidney to one of the many young men who needed one. After his daughter was born, he went to the hospital to find a patient.

One day as Sampath lay in the dialysis ward, the stranger approached and offered to donate his kidney. Ajantha is one of hundreds of Buddhists, most of them monks, donating their kidneys to strangers due to their spiritual beliefs.

In Sri Lanka’s devout North Central province, where CKDu has become the leading cause of death, these orange and red-robed priests are revered by the population and supported by its alms. A nephrologist at a hospital in central Sri Lanka estimated that about one of the three transplants his unit performs each week relies on an altruistic donor.

“He said he is not doing it for money,” Sampath’s mother, Manike, said of Ajantha, who is Buddhist but not a monk. “I can only bless him as I have nothing to give.”

Tests confirmed that her son and Ajantha were a match. Sampath’s transplant is set to be one of the first performed at Anuradhapura General Hospital, a public hospital whose nephrology unit serves the entire northern region affected by the disease.

The operation will expand a growing program to provide patients with the only real solution to advanced CKD: kidney transplants.

Mehinthe Dhammarakkita gave his kidney when he was 28. As a boy, he had seen his ailing uncle receive a kidney transplant, and then go on to survive for more than 20 years. The monk was moved to donate his own kidney after visiting a village where he met sick patients who would die without a transplant.

“I thought about the impermanence of life and how our bodies will anyway be absorbed to the soil one day,” Dhammarakkita said. “If one can make a sacrifice when we are alive, one can gain some spiritual happiness.”

Dhammarakkita seeks to inspire villagers with his example and then connect them with patients in need. It was Dhammarakkita who provided the unseen link in Sampath’s apparent miracle — informing Ajantha of his plight. "If we can donate a part of our body to someone, there are no words to describe the happiness it gives,” Dhammarakkita said.

Although kidney donations in Sri Lanka are growing, they are provided to only a fraction of patients. The disease still overwhelms the health system, and the vast majority of eligible patients cannot receive dialysis, let alone transplants.

As he awaits his operation, Sampath continues to make the 8-hour journey to and from Anuradhapura Hospital twice a week. On a warm day in July, nurses dote on the young patient as they insert needles into his neck for his four-hour dialysis session. He flashes a smile, his teeth stained red with the juice of the betel nuts he frequently chews.

“I am happy,” he said, “but I do have some fear as well.”

RELATED: Listen to "Sri Lanka: Kidney Ailment Linked to Farm Chemicals" from PRI's "The World."

Watch Doctors Are Charging More for Medicare Patients on PBS. See more from PBS NewsHour.

Our story on Chronic Kidney disease in Sri Lanka was reported in conjunction with PRI’s The World. Listen to Rhitu Chatterjee's story.

Conservative nonprofit American Action Network and its sister super PAC, the Congressional Leadership Fund, have launched a multi-million campaign targeting top congressional races.

The groups, which were both founded by former GOP Sen. Norm Coleman and ex-Nixon aide Fred Malek, are spending more than $3 million on ads designed to aid Republicans, with $1.6 million of that coming from the American Action Network, according to a press release from the group.

With just seven weeks until Election Day, the spending comes as part of an advertising barrage on down-ticket races, where groups can often get more bang for their buck. Conservative super PACs American Crossroads and YG Action Fund have also announced plans to target House races in hopes of helping the GOP maintain the majority.

The four ads released by American Action Network Monday targeted races in Minnesota, Illinois and California:

• “Dangerous,” and “Sides,” oppose former Rep. Rick Nolan, a Democrat, who is running for Congress in Minnesota’s 8th District against Republican Rep. Chip Cravaack. “Dangerous” is running in the Minneapolis media market, and “Sides” is running in Duluth, Minn., according to a press release.
• “Radical Ideas” opposes physician David Gill, a Democrat, in Illinois’ 13th District. Gill faces Republican Rodney Davis, a former aide to Rep. John Shimkus, R-Ill. The ad is running in the St. Louis media market.
• “Neighbor” opposes astronaut Jose Hernandez, a Democrat, in California’s 10th District. Hernandez is challenging Rep. Jeff Denham, the Republican incumbent. The ad is running in the Sacramento media market.

American Action Network is organized under section 501(c)(4) of the U.S. tax code, meaning its primary purpose is the promotion of “social welfare,” not electoral politics. It has frequently been criticized by Democratic politicians and campaign finance reformers for being too focused on election-related advertising.

As a nonprofit, American Action Network is not required to publicly disclose its donors. Some donors, however, have been revealed.

For instance, Pharmaceutical Research and Manufacturers of America (PhRMA) gave American Action Network $4.5 million in 2010, as the Center for Public Integrity previously noted. Additionally, the Center for Responsive Politics found that Crossroads GPS, the Republican Jewish Coalition, the Wellspring Committee and the American Natural Gas Alliance have also contributed to the group.

American Action Network has reported making $1.6 million in independent expenditures so far this election, according to the Center for Responsive Politics. According to Politico, it is committed to spending at least $10 million on House races, which are especially vulnerable to outside spending.

Meanwhile, the Congressional Leadership Fund released “Sutton Works for Pelosi,” which opposes Rep. Betty Sutton, D-Ohio. Sutton is running against Republican Rep. Jim Renacci in Ohio’s redrawn 16th District. The ad cost $558,000, according to a report filed with the Federal Election Commission, as the Center for Public Integrity reported Monday.

The Congressional Leadership Fund is backed by super donors Sheldon and Miriam Adelson and Bob Perry. The super PAC’s only reported expenditure so far is the anti-Sutton ad.

In other outside spending news:

• Conservative super PAC Ending Spending Action Fund began a $10 million campaign called “Agents of Change.” The campaign features voters who supported President Barack Obama in 2008 explaining why they are voting for GOP presidential nominee Mitt Romney this year.
   
• The Democratic Congressional Campaign Committee released an ad opposing Republican Rep. Denny Rehberg, who is running for U.S. Senate in Montana against Sen. Jon Tester, a Democrat.
   
• The DCCC also released “Broken Record,” opposing Rep. Bobby Schilling, R-Ill. Schilling was also hit with “Time” from House Majority PAC, a pro-Democrat super PAC. He faces a challenge from Democrat Cheri Bustos, a former reporter and nonprofit executive.
   
• House Majority PAC also released three other ads: “Principle,” which opposes Rep. Charlie Bass, R-N.H., who faces a challenge from Democratic attorney Ann McLane Kuster; “Profits,” which opposes Rep. Jim Renacci, R-Ohio, who faces Democratic Rep. Betty Sutton in Ohio’s 16th District; and “Under Attack,” which opposes Republican John Koster, a county councilman, who is facing off with former Microsoft executive Suzan DelBene, a Democrat, in Washington’s 1st District.
   
• The Democratic Senatorial Campaign Committee reported spending $482,000 opposing Sen. Dean Heller, a Republican who faces a challenge from Democratic Rep. Shelley Berkley. A new ad from the group criticizes Heller’s support for Republican vice presidential nominee Paul Ryan’s “premium support” Medicare plan.
   
• Center Forward, a nonprofit supporting centrist candidates, has released two new ads. The first, “Skyrocket,” criticizes Republican Mayor Mia Love of Saratoga Springs, Utah, for her record on fighting crime. Love is challenging Democratic Rep. Jim Matheson in Utah’s new 4th District. The second, “Blackboard,” opposes Georgia state Rep. Lee Anderson, a Republican challenging Democratic incumbent John Barrow in Georgia’s 12th District.
   
• “Obama’s Legacy of Failure” from the PAC Campaign to Defeat Barack Obama criticizes the president for high unemployment rates, “failed” foreign policy and other issues, including claims debunked by the nonpartisan FactCheck.org.
   
• AFSCME PEOPLE, the PAC of the American Federation of State, County and Municipal Employees union, has released two new ads. One, called “Rooster,” opposes Republican business executive Joe Coors, who is trying to unseat Democratic Rep. Ed Perlmutter in Colorado’s 7th District. The other, called “Regular Guy,” opposes Republican attorney Keith Rothfus, who is challenging Democratic Rep. Mark Critz in Pennsylvania’s 12th District. The latter ad calls Rothfus a “regular phony” for his claim to be a “regular guy” despite representing a “Wall Street bank.” The bank in question is Bank of New York Mellon, which, while located on Wall Street, also employs 7,500 people in the Pittsburgh area.

For up-to-date news on outside money in the election, follow our Source2012 Tumblr and the hashtag #Source2012 on Twitter.

Mystery in the Fields, a three-part series, explores how a rare form of kidney disease is killing laborers and crippling communities in three different regions, from Central America to Sri Lanka to India. As death tolls mount, researchers remain puzzled, unable to definitively uncover the disease’s causes.

The series is an outgrowth of an earlier investigation, “Island of the Widows,” published last December in the Center for Public Integrity and its International Consortium of Investigative Journalists. In that piece, reporter Sasha Chavkin exposed how chronic kidney disease was so prevalent in some regions of Central America it left communities filled with widows and scientists searching for answers.

Building from that research, Chavkin discovered that the disease had also developed in clusters in India and Sri Lanka. Over several months this year, he and video journalist Anna Barry-Jester traveled to the countries to tell the story from the ground, and pressed governments and leaders of the medical community for answers.

Their report is also being published or aired in news outlets including PRI’s The World, the BBC, The Sunday Times of Sri Lanka and The Week in India.

Project staff

Reporter: Sasha Chavkin

Photographer/videographer: Anna Barry-Jester

Web team: Christine Montgomery, Paul Williams, Sarah Whitmire

Fact-checking: Peter Newbatt Smith

Project Editor: Ronnie Greene

Meridian is not alone under the Justice Department magnifying glass. In a somewhat similar case in Tennessee,  DOJ says the Juvenile Court of Memphis and Shelby County has failed both to inform children of the charges against them and to make sure they understand what their legal rights are ahead of questioning. Like Meridian, the juvenile court is also accused of failing to hold timely hearings.

Worries about a school-to-prison pipeline have grown in recent years, but there are different ways to define the issue, said Jim Freeman, senior attorney at Advancement Project, a nonprofit legal action group that fights racial injustice.

“How I like to define it,” Freeman said, “is the use of policies and practices that increase the likelihood that young people become incarcerated.”

That includes at-school arrests for minor behavioral incidents, as well as what he calls more indirect actions, like suspensions, expulsions or references to juvenile court or alternative schools.

Such practices have grown in the last 10 to 15 years, he said. “It really started out mostly in very low income communities of color, the schools in those districts. It’s expanded pretty dramatically beyond that.”

In a high-profile Delaware case in 2009, a six-year-old was almost suspended for 45 days for having his Cub Scout knife at school. The school board intervened to cut that to three to five days.

The combination of zero-tolerance school rules, themselves fueled by safety fears, and the kind of high-stakes testing required by the federal government “create some of these dynamics,” Freeman contended.

Mississippi was under the high-stakes testing regime of the federal No Child Left Behind law until it won a waiver in July 2012.

Low-performing schools are under such pressure to meet testing benchmarks that some neglect the education of some struggling students, even pushing them out of school, reports suggest. Data compiled in a 2010 Advancement Project report finds that in several U.S. states, there was a link between the adoption of high-stakes testing and increased use of suspensions and expulsions.

“Race has certainly played a role in where we have elected to implement these policies and practices,” Freeman added, “I think the data is pretty clear.”

By mid-October Meridian, Miss. could land in court because of the federal investigators’ allegations. The DOJ threatened to file suit by then if the city and county and state agencies don’t start “meaningful negotiations” with the federal agency.

Politicians who are promising to repeal ObamaCare won’t find any evidence in the Kaiser Family Foundation’s analysis of health insurance costs that the law has caused premiums to skyrocket, as many of those politicians have contended.

On the contrary, premiums have increased on average only 4 percent over the past year, the lowest rate of increase in years, according to Kaiser’s 2012 Employer Health Benefits Survey, which was released last week. Double-digit premium increases were once the norm, especially during the George W. Bush administration. Premiums increased 10 percent in 2004 and 13 percent in 2003.

So the good news is that premiums increased only 4 percent. The not so good news is that, because of all those past double-digit increases, the average premium for employer-sponsored health coverage has reached a record high of $15,745. And because employers have been shifting more and more of the cost of coverage to workers, employees are now paying, on average, nearly 30 percent of that total, much more than they used to. The hike in worker contributions has far outstripped the overall rise in premiums.    

A study published last year in Health Affairs found that the gains in wages U.S. workers made over the past decade were more than wiped out by increases in the cost of health care and health insurance. Kaiser’s annual surveys document that: since 2002, premiums have increased 97 percent, which is three times as fast as wages (33 percent) and inflation (28 percent).

That’s not all the bad news, unfortunately. More Americans are now enrolled in high deductible plans, because that’s frequently all their employers are offering. Kaiser found that the percentage of workers enrolled in plans with an annual deductible of $1,000 or more has increased from 10 percent in 2006 to 34 percent in 2012. The growth has been even greater for employees of small firms.

It gets worse. Many workers are now longing for the good old days of having to pay “just” $1,000 in deductibles. Fourteen percent of workers are now in plans with deductibles of $2,000 or more, compared to 3 percent in 2006.

And those numbers are just for single coverage. Families are getting hit much harder. Workers enrolled in high deductible plans are now facing annual family deductibles of almost $4,000 on average.  Many have much, much higher deductibles.

As troubling as those numbers are, it is all too easy when we look at them for our eyes to glaze over and to forget that we are talking about real people. But because of these trends, increasing numbers of us are finding it impossible to get the care we need, even if we have insurance.

A couple of days after the Kaiser study was released, Consumer Reports released a study of its own showing that over the past year, 45 percent of adults under the age of 65 skipped getting a prescription and 63 percent canceled a doctor’s appointment, even though they were sick, to save money. Many others decided not to get a doctor-ordered test or undergo a needed medical procedure.

An untold number of Americans undoubtedly did go forward with a procedure their doctors said was necessary to save their lives and, as a consequence, are now facing bankruptcy.

Like the mother of a friend of mine whose doctor discovered through expensive testing last year that she had a pancreatic tumor. Thinking she had adequate coverage through her employer, Federal Express, the woman agreed to surgery. Fortunately, it was successful.  Her doctors say she is cancer free, at least for now. Unfortunately, she hadn’t paid much attention to how much the surgery would cost because of her switch a few years ago into a high-deductible plan.

A single mother who, according to her daughter, lives paycheck to paycheck, she was in shock as the medical bills started pouring in. When they reached $6,000, which she was obligated to pay, she decided she had no choice but to file for bankruptcy.

For political candidates who make hundreds of thousands of  dollars a year, $6,000 is pocket change. For most Americans, however, suddenly owing that much money can mean financial ruin.  If ObamaCare goes forward, beginning in 2014, the law will set a cap on out-of-pocket spending. That  cap will still be too high to keep some of us out of bankruptcy court. If the law is repealed, however, many more of us undoubtedly will wind up there.

Tea-party aligned super PAC FreedomWorks for America released 11 new ads over the weekend targeting hotly contested U.S. Senate races in Florida, Arizona, Ohio, Indiana and Virginia:

• “The American Dream” supports the U.S. Senate run of Rep. Connie Mack, R-Fla., who is challenging Democratic Sen. Bill Nelson;
• “Failing Florida” opposes Nelson;
• “Handpicked by Obama” opposes Democrat Richard Carmona, who served as President George W. Bush’s surgeon general and is now running for U.S. Senate in Arizona against Rep. Jeff Flake, a Republican;
• “A Proven Leader” supports Flake;
• “Dividing Ohio” and “Politics before Ohio” opposes Sen. Sherrod Brown, D-Ohio, who faces Republican Josh Mandel, the state’s treasurer;
• “Take Back America” supports Mandel;
• “Don’t Trust His Record” opposes Rep. Joe Donnelly, D-Ind., who is running for U.S. Senate against Indiana State Treasurer Richard Mourdock;
• “A Good Hoosier” supports Mourdock, who won a contested GOP primary earlier this year;
• “George Allen Stands Strong for Freedom” supports the former Republican senator’s run for U.S. Senate in Virginia;
• “You Didn’t Build That” criticizes Allen’s Democratic opponent, former Virginia Gov. Tim Kaine.

FreedomWorks for America is the super PAC component of the former Republican House Majority Leader Dick Armey’s FreedomWorks network. The super PAC supports economically conservative candidates and has helped tea party-favored candidates triumph over establishment Republican candidates in several senatorial primaries, notably Indiana and Texas, where former state Solicitor General Ted Cruz bested Lt. Gov. David Dewhurst.

The five U.S. Senate races targeted over the weekend are particularly competitive. Florida and Ohio lean Democrat and both have Democratic incumbents. Arizona and Indiana, both open seats, lean Republican. Virginia, also an open seat, is a tossup, according to The New York Times.

The U.S. Senate contests in Virginia and Ohio have drawn more outside money than almost any other Senate race, according to the Center for Responsive Politics.

Records show that more than one-third of contributions to FreedomWorks for America have come from its affiliated nonprofit, FreedomWorks Inc., which means the source of the money is unknown. (Nonprofits are generally not required to publicly report their donors.)

Ryan Hecker, the super PAC's treasurer and legal counsel, said the ads are just online for now, and the group's initial online ad buy totals about $200,000.

The super PAC has made $3.1 million in independent campaign expenditures so far, according to the Center for Responsive Politics.

FreedomWorks was also on the ground on Saturday in Ohio, where its National FreePAC Tour featured Mandel, conservative radio host Glenn Beck and FreedomWorks president Matt Kibbe. The event included grassroots training on phone banking, yard sign “blitzes” and door-to-door outreach. The tour will stop in Florida in October.

In other outside spending news:

• The Congressional Leadership Fund, a conservative super PAC backed by super donors Sheldon and Miriam Adelson and Bob Perry, reported its first independent expenditure — $558,000 in television ads opposing the re-election of Rep. Betty Sutton, D-Ohio. Sutton faces Republican Rep. Jim Renacci in Ohio’s redrawn 16th Congressional District, a tossup race.
   
• AFSCME PEOPLE, the PAC of the American Federation of State, County and Municipal Employees, reported spending $541,000 on “Didn’t Take Long,” an ad opposing Renacci in Ohio. AFSCME also spent $360,000 from its union treasury on “Gamble” and $422,000 on “A Lot to Say,” both of which oppose Rep. Denny Rehberg, R-Mont., who is running for U.S. Senate against Democratic incumbent Jon Tester.
   
• The Democratic Senatorial Campaign Committee reported spending $1.3 million on ads opposing Republican candidates for the U.S. Senate: Rehberg in Montana, Mandel in Ohio, former Gov. Tommy Thompson in Wisconsin and former wrestling executive Linda McMahon in Connecticut.
   
• The Democratic Congressional Campaign Committee reported spending $244,000 opposing Republican House candidates in five districts. The DCCC also released "Only in Washington" opposing the re-election of Rep. Ann Marie Buerkle, R-N.Y.
   
• Conservative nonprofit Crossroads GPS reported spending $5.3 million on ads opposing President Barack Obama. Additionally, its sister super PAC American Crossroads released “Skips,” which accuses Obama of absenteeism in the White House. “Mr. President, it’s time to show up for work,” the ad states. Politics365 has noted that in his first three years in office Obama took less than half the amount of vacation as his predecessor, Republican George W. Bush, who spent 180 days on vacation during his first three years in office.
   
• On Friday, pro-Democrat House Majority PAC reported spending $452,000 opposing Republican House candidates in four districts. On Saturday, it reported an additional $1.3 million in ads opposing Republicans in 10 districts.
   
• Majority PAC, a super PAC supporting Democratic candidates for U.S. Senate, reported $319,000 in ads opposing Tommy Thompson in Wisconsin, who faces Democratic Rep. Tammy Baldwin in the state’s U.S. Senate contest.
   
• The National Republican Senatorial Committee reported spending $1 million opposing Democratic Senate candidates Heidi Heitkamp in North Dakota and Jon Tester in Montana, as well as independent Angus King in Maine. The National Republican Congressional Committee reported spending $4.1 million on ads opposing Democrats in numerous House districts.
   
• The super PAC Treasure Coast Jobs Coalition reported spending $507,000 opposing Democrat Patrick Murphy, the vice president of an environmental cleanup firm, who is running for U.S. House against tea party favorite Rep. Allen West. This is the group’s only reported expenditure.
   
• SEIU COPE, the political action committee of the Service Employees International Union, reported spending $858,000 on ads opposing Republicans and supporting Democrats in House, Senate and presidential races.
   
• American Action Network, a conservative nonprofit, spent a total $416,000 on ads opposing the House runs of former Rep. Nick Nolan, D-Minn., and Democrat David Gill in Illinois. Nolan faces Republican Rep. Chip Cravaack, and Gill, a physician, faces Republican Rodney Davis, a congressional aide.

For up-to-date news on outside money in the election, follow our Source2012 Tumblr and the hashtag #Source2012 on Twitter.

KEBITHIGOLLEWA, Sri Lanka — For two decades, chronic kidney disease has been a mystery and death sentence in Sri Lanka, striking 15 percent of the residents of its north central region.

This summer, after years of secretive official research, a glimmer of scientific hope emerged. The government and World Health Organization announced in June that they identified a key cause of the disease in Sri Lanka: chronic exposure to arsenic and cadmium, likely consumed in food.

Yet in a disease that has confounded experts across continents, even potential breakthroughs come with asterisks. The new report left huge questions unanswered — including where in the country the toxins were found, how they entered the food and what foods were contaminated. The key unsolved question: the extent fertilizers and pesticides contributed to the outbreak.

In Sri Lanka’s lush northern farmlands, the mystery and the death sentences continue. Lacking firm answers from the scientific community, some victims’ best hope for survival comes through the spiritual community — and offers of kidney transplants from Buddhist monks and those they inspire to make extraordinary sacrifices for strangers.

At 21, Sampath Kumarasinghe is among the victims awaiting that miracle.

The soft-spoken farmer was diagnosed last September with kidney damage so severe it had reached its terminal phase: end stage renal disease. Healthy his entire life, he suddenly became feverish and too sick to work in the rice paddies. His mother mortgaged their land to pay for his medical care, and they began the search for a kidney donor. One day, like a vision, a man appeared in his hospital offering to donate his kidney.

“I am only thinking of ways to save my son’s life,” said Sampath’s mother, Punchirilalage Dingiri Manike. “That is what I think of day and night.”

Sampath is among the youngest victims of a broad epidemic of chronic kidney disease sweeping north central Sri Lanka. Its victims are mostly male agricultural workers who do not suffer from diabetes or hypertension, the usual causes of the illness. The government and WHO call it CKDu: chronic kidney disease of unknown etiology.

Winding path to answers

CKDu emerged in Sri Lanka’s north central farmlands, known as the “rice bowl,” in the 1990s. Physicians began noticing clusters of kidney failure in which four or five members of a single household had the disease. Rezvi Sheriff, who began practicing in the 1970s as Sri Lanka’s first nephrologist and is the unofficial dean of the country’s kidney doctors, calls it a recent phenomenon.

“In the last 20 years or so,” Sheriff said, “we have noticed it.”

Researchers developed a succession of theories to try to explain the outbreak, from cyanobacteria to fluoride to aluminum pots and pans, but none settled the debate. The conflicting alarms spread fear and confusion among villagers.

The unsolved mystery became an embarrassment to the Sri Lankan government, whose leaders take pride in the health system despite the country’s per capita GDP of roughly $5,600 — less than one-eighth that of the United States. The country points to infant and maternal mortality rates approaching those in the U.S. and Europe.

In 2008, Sri Lanka’s Health Ministry invited the World Health Organization to join a comprehensive study to unravel the disease’s roots.

For more than three years, no results were announced publicly. “Releasing information piecemeal is not the solution for the problem,” said Dr. Shanthi Mendis, Coordinator and Senior Adviser of the WHO non-communicable disease program and the lead adviser of its efforts in Sri Lanka.

Scientific alarms sounded elsewhere. A group of researchers from Sri Lanka’s University of Kelaniya released studies citing widespread arsenic contamination in drinking water, food and soil — and blaming pesticides. In June 2011, several common pesticides were found by the government to have small amounts of arsenic, and briefly banned from importation.

The Kelaniya group’s findings provoked a storm of condemnation: some scientists questioned their methods, and government officials and Sri Lanka’s agribusinesses sector accused them of harming the country.

"Loose tongues and irresponsible reporting could lead to irrevocable repercussions in the export sector and thereby adversely affect the whole economy of Sri Lanka,” Dr. Anura Wijesekara, Sri Lanka’s registrar of pesticides, wrote in a column in The Island newspaper. “One interested group has already termed this as As [arsenic] terrorism.”

Two months later, Wijesekara lifted the ban on the pesticide imports. He did so, he said in an interview, because the amount of arsenic they contained was too small to pose danger. “It’s not a big deal to have so little amount of arsenic in a pesticide because arsenic is a natural element,” Wijesekara said.

Yet in the months before the ban was lifted, the official CKDu study group was internally warning of the “imperative” of stronger regulations for “nephrotoxic agrochemicals.” A WHO meeting report from June 2011, obtained by the Center for Public Integrity, cautioned that failure to act quickly could “result in cumulative damage to the health of the people living in these areas.”

A full year later, in June 2012, the government and WHO released partial findings, concluding that exposure to low concentrations of cadmium and arsenic is a key cause of the epidemic.

“The data that we have got up until now show that it’s a combination of nephrotoxic heavy metals,” said Mendis of the WHO. “For the moment all we know is that these heavy metals have entered the food chain.”

Still, much remains unknown. The government and WHO said that lab results found small amounts of heavy metals in CKDu patients’ blood and urine, but did not specify how much. Researchers said the metals got there through the food chain — and not through the widely suspected vector of drinking water — but will not say which foods were contaminated. Mendis said a technical report to be released in late October will lay out the details.

Agneta Åkesson, a toxicologist at the Karolinska Institute who specializes in cadmium poisoning, reviewed three WHO meeting reports describing Sri Lanka’s findings through February 2012. These notes, obtained by the Center for Public Integrity and described as “administrative” by the WHO, include the results of many of the biological and environmental tests.

“Based on what’s written here, you cannot conclude anything,” Åkesson said. In the absence of any newer evidence, she said, the exposure levels described were “not enough to cause chronic kidney failure.”

The results also offered no explanation of how the heavy metals entered the food.

A leading suspect is agrochemicals, which are heavily used in the affected area’s rice paddies. Cadmium is frequently present in phosphate fertilizers and can accumulate in soil; several pesticides in Sri Lanka contain small quantities of arsenic. Some regions of the world also have low levels of arsenic that naturally occur in the environment.

The official study’s research of pesticides and fertilizers remains incomplete.

To some, the government and WHO’s reticence to release more information raises the possibility that the undisclosed evidence points toward the agrochemicals and rice crops that form the economic backbone of Sri Lanka’s long-suffering northern countryside.

Dr. Channa Jayasumana, one of the Kelaniya scientists, said that in a private meeting with his group in August the health ministry acknowledged the role of fertilizers and pesticides. A primary culprit, he said, is a fertilizer called triple superphosphate, which will be targeted for reduction in the next growing season.

“They have narrowed down the problem to heavy metals and realized the importance of fertilizers and pesticides,” Jayasumana said.

The health ministry and WHO did not respond to inquiries as to whether they had identified rice, pesticides or fertilizers such as triple superphosphate as leading sources of heavy metal exposure.

The agribusiness industry says it’s possible heavy metals contribute to the disease — but that the theory remains unproven, and dangerous levels of heavy metals could not have come from their products.

The cause could be “cadmium or arsenic,” said Rohitha Nanayakkara, Secretary of the National Agrobusiness Council. “But what we say is it can't be from pesticides, because the quantities included in pesticides are minimal.”

Meantime, the government continues to import — and farmers continue to apply — thousands of tons of agrochemicals to the fertile paddies blanketing the farmlands of Sri Lanka.

Kidneys for Strangers

As officials debate their next steps, another movement is bringing hope to Sampath and others suffering from CKDu.

As Sampath was falling ill, a man in a distant village, W.B. Ajantha, made an unusual vow. When his wife became pregnant, Ajantha promised to Buddha that he would donate his kidney to one of the many young men who needed one. After his daughter was born, he went to the hospital to find a patient.

One day as Sampath lay in the dialysis ward, the stranger approached and offered to donate his kidney. Ajantha is one of hundreds of Buddhists, most of them monks, donating their kidneys to strangers due to their spiritual beliefs.

In Sri Lanka’s devout North Central province, where CKDu has become the leading cause of death, these orange and red-robed priests are revered by the population and supported by its alms. A nephrologist at a hospital in central Sri Lanka estimated that about one of the three transplants his unit performs each week relies on an altruistic donor.

“He said he is not doing it for money,” Sampath’s mother, Manike, said of Ajantha, who is Buddhist but not a monk. “I can only bless him as I have nothing to give.”

Tests confirmed that her son and Ajantha were a match. Sampath’s transplant is set to be one of the first performed at Anuradhapura General Hospital, a public hospital whose nephrology unit serves the entire northern region affected by the disease.

The operation will expand a growing program to provide patients with the only real solution to advanced CKD: kidney transplants.

Mehinthe Dhammarakkita gave his kidney when he was 28. As a boy, he had seen his ailing uncle receive a kidney transplant, and then go on to survive for more than 20 years. The monk was moved to donate his own kidney after visiting a village where he met sick patients who would die without a transplant.

“I thought about the impermanence of life and how our bodies will anyway be absorbed to the soil one day,” Dhammarakkita said. “If one can make a sacrifice when we are alive, one can gain some spiritual happiness.”

Dhammarakkita seeks to inspire villagers with his example and then connect them with patients in need. It was Dhammarakkita who provided the unseen link in Sampath’s apparent miracle — informing Ajantha of his plight. "If we can donate a part of our body to someone, there are no words to describe the happiness it gives,” Dhammarakkita said.

Although kidney donations in Sri Lanka are growing, they are provided to only a fraction of patients. The disease still overwhelms the health system, and the vast majority of eligible patients cannot receive dialysis, let alone transplants.

As he awaits his operation, Sampath continues to make the 8-hour journey to and from Anuradhapura Hospital twice a week. On a warm day in July, nurses dote on the young patient as they insert needles into his neck for his four-hour dialysis session. He flashes a smile, his teeth stained red with the juice of the betel nuts he frequently chews.

“I am happy,” he said, “but I do have some fear as well.”

RELATED: Listen to "Sri Lanka: Kidney Ailment Linked to Farm Chemicals" from PRI's "The World."

Conservative nonprofit American Action Network and its sister super PAC, the Congressional Leadership Fund, have launched a multi-million campaign targeting top congressional races.

The groups, which were both founded by former GOP Sen. Norm Coleman and ex-Nixon aide Fred Malek, are spending more than $3 million on ads designed to aid Republicans, with $1.6 million of that coming from the American Action Network, according to a press release from the group.

With just seven weeks until Election Day, the spending comes as part of an advertising barrage on down-ticket races, where groups can often get more bang for their buck. Conservative super PACs American Crossroads and YG Action Fund have also announced plans to target House races in hopes of helping the GOP maintain the majority.

The four ads released by American Action Network Monday targeted races in Minnesota, Illinois and California:

• “Dangerous,” and “Sides,” oppose former Rep. Rick Nolan, a Democrat, who is running for Congress in Minnesota’s 8th District against Republican Rep. Chip Cravaack. “Dangerous” is running in the Minneapolis media market, and “Sides” is running in Duluth, Minn., according to a press release.
• “Radical Ideas” opposes physician David Gill, a Democrat, in Illinois’ 13th District. Gill faces Republican Rodney Davis, a former aide to Rep. John Shimkus, R-Ill. The ad is running in the St. Louis media market.
• “Neighbor” opposes astronaut Jose Hernandez, a Democrat, in California’s 10th District. Hernandez is challenging Rep. Jeff Denham, the Republican incumbent. The ad is running in the Sacramento media market.

American Action Network is organized under section 501(c)(4) of the U.S. tax code, meaning its primary purpose is the promotion of “social welfare,” not electoral politics. It has frequently been criticized by Democratic politicians and campaign finance reformers for being too focused on election-related advertising.

As a nonprofit, American Action Network is not required to publicly disclose its donors. Some donors, however, have been revealed.

For instance, Pharmaceutical Research and Manufacturers of America (PhRMA) gave American Action Network $4.5 million in 2010, as the Center for Public Integrity previously noted. Additionally, the Center for Responsive Politics found that Crossroads GPS, the Republican Jewish Coalition, the Wellspring Committee and the American Natural Gas Alliance have also contributed to the group.

American Action Network has reported making $1.6 million in independent expenditures so far this election, according to the Center for Responsive Politics. According to Politico, it is committed to spending at least $10 million on House races, which are especially vulnerable to outside spending.

Meanwhile, the Congressional Leadership Fund released “Sutton Works for Pelosi,” which opposes Rep. Betty Sutton, D-Ohio. Sutton is running against Republican Rep. Jim Renacci in Ohio’s redrawn 16th District. The ad cost $558,000, according to a report filed with the Federal Election Commission, as the Center for Public Integrity reported Monday.

The Congressional Leadership Fund is backed by super donors Sheldon and Miriam Adelson and Bob Perry. The super PAC’s only reported expenditure so far is the anti-Sutton ad.

In other outside spending news:

• Conservative super PAC Ending Spending Action Fund began a $10 million campaign called “Agents of Change.” The campaign features voters who supported President Barack Obama in 2008 explaining why they are voting for GOP presidential nominee Mitt Romney this year.
   
• The Democratic Congressional Campaign Committee released an ad opposing Republican Rep. Denny Rehberg, who is running for U.S. Senate in Montana against Sen. Jon Tester, a Democrat.
   
• The DCCC also released “Broken Record,” opposing Rep. Bobby Schilling, R-Ill. Schilling was also hit with “Time” from House Majority PAC, a pro-Democrat super PAC. He faces a challenge from Democrat Cheri Bustos, a former reporter and nonprofit executive.
   
• House Majority PAC also released three other ads: “Principle,” which opposes Rep. Charlie Bass, R-N.H., who faces a challenge from Democratic attorney Ann McLane Kuster; “Profits,” which opposes Rep. Jim Renacci, R-Ohio, who faces Democratic Rep. Betty Sutton in Ohio’s 16th District; and “Under Attack,” which opposes Republican John Koster, a county councilman, who is facing off with former Microsoft executive Suzan DelBene, a Democrat, in Washington’s 1st District.
   
• The Democratic Senatorial Campaign Committee reported spending $482,000 opposing Sen. Dean Heller, a Republican who faces a challenge from Democratic Rep. Shelley Berkley. A new ad from the group criticizes Heller’s support for Republican vice presidential nominee Paul Ryan’s “premium support” Medicare plan.
   
• Center Forward, a nonprofit supporting centrist candidates, has released two new ads. The first, “Skyrocket,” criticizes Republican Mayor Mia Love of Saratoga Springs, Utah, for her record on fighting crime. Love is challenging Democratic Rep. Jim Matheson in Utah’s new 4th District. The second, “Blackboard,” opposes Georgia state Rep. Lee Anderson, a Republican challenging Democratic incumbent John Barrow in Georgia’s 12th District.
   
• “Obama’s Legacy of Failure” from the PAC Campaign to Defeat Barack Obama criticizes the president for high unemployment rates, “failed” foreign policy and other issues, including claims debunked by the nonpartisan FactCheck.org.
   
• AFSCME PEOPLE, the PAC of the American Federation of State, County and Municipal Employees union, has released two new ads. One, called “Rooster,” opposes Republican business executive Joe Coors, who is trying to unseat Democratic Rep. Ed Perlmutter in Colorado’s 7th District. The other, called “Regular Guy,” opposes Republican attorney Keith Rothfus, who is challenging Democratic Rep. Mark Critz in Pennsylvania’s 12th District. The latter ad calls Rothfus a “regular phony” for his claim to be a “regular guy” despite representing a “Wall Street bank.” The bank in question is Bank of New York Mellon, which, while located on Wall Street, also employs 7,500 people in the Pittsburgh area.

For up-to-date news on outside money in the election, follow our Source2012 Tumblr and the hashtag #Source2012 on Twitter.

How mainstream has advocating for public financing of elections become?  So mainstream that moderate North Dakota Democrat Byron Dorgan endorsed the idea in an op-ed in Politico last week.

“Government is now being bought and sold on the auction block by unlimited money from anonymous buyers,” Dorgan, a former U.S. senator who was not known as a campaign finance firebrand, lamented in the piece. “The world’s greatest democracy is now witnessing the disgrace of its government being sold to the highest bidder.”

In the op-ed, Dorgan advocated for the passage of the DISCLOSE Act, legislation that he twice supported against GOP filibusters in the Senate. The bill is designed to create new reporting requirements for groups that air political advertisements.

But the campaign finance reforms Dorgan has come to embrace don’t stop there.

For the first time, Dorgan also endorsed legislation sponsored by Sen. Dick Durbin (D-Ill.) that would create public financing for congressional elections as a “worthy idea.” And he recommended passage of a constitutional amendment aimed at mitigating the effects of the U.S. Supreme Court’s 2010 Citizens United ruling that lifted restrictions on corporate and union spending on election ads. The op-ed also marks the first time that Dorgan has endorsed this proposal.

“I really think we’ve reached a tipping point,” Dorgan told the Center for Public Integrity in a telephone interview.

“I hope both political parties and people of all political persuasions will see this and be sickened by what’s happened to campaign finance,” he continued. “If we don’t fix this, there’s no honor in the way we select our leaders.”

While in the Senate, Dorgan never co-sponsored Durbin’s bill, and during his time as a federal candidate, he often relied on traditional sources of campaign cash: lobbyists and political action committees.

According to the nonpartisan Center for Responsive Politics, Dorgan raised more than $13.3 million over his career, with $6.6 million coming from PACs. And over his career, individual lobbyists, as well as PACs of lobbying firms, gave Dorgan about $650,000, according to the Center for Responsive Politics — more than any other industry except law firms.

During the scandal surrounding Jack Abramoff in 2005, Dorgan returned $67,000 in contributions from clients of the super lobbyist, whom Dorgan, then the ranking Democrat on the Senate’s Indian Affairs Committee, stressed that he never met. In 2006, Abramoff pled guilty to charges associated with defrauding Indian tribes that he represented of millions of dollars, as well as corrupting public officials.

Campaign finance reformers are welcoming Dorgan’s shift.

“It does not surprise me that a moderate Democrat would come out in support of a constitutional amendment,” said Craig Holman, a lobbyist for the consumer rights group Public Citizen. “Adding his voice helps.”

Common Cause President Bob Edgar was even more effusive.

“His statement reads as if it could have been written by Common Cause,” Edgar said. “If Byron wants to come on the board of Common Cause, we’d welcome him.”

Dorgan’s op-ed comes on the heels of the Democratic Party’s national convention in Charlotte, where officials rolled out a platform that supports “campaign finance reform, by constitutional amendment if necessary,” as well as legislation to “require greater disclosure of campaign spending,” as the Center for Public Integrity previously reported.

The Citizens United ruling has also become a rallying cry among party activists and is frequently incited as a reason to donate to Democratic caucuses.

Earlier this month, for instance, Sen. Patty Murray, D-Wash., chair of the Democratic Senatorial Campaign Committee, referenced the controversial court case five times in a direct mail solicitation obtained by the Center for Public Integrity.

“Please do not let the hundreds of millions in Citizens United corporate dollars decide who will run your country,” Murray pleaded.

The campaign of President Barack Obama has also emphasized the threat of “billionaires and super PACs” that are seeking to defeat the president.

“We don't have Sheldon Adelson, and with all due respect, we don't want him,” Obama campaign adviser David Axelrod said of the deep-pocketed casino magnate in an e-mail to donors Friday. “Let's make sure this election is decided by millions of Americans, not a handful of billionaires.”

Thanks to the fallout from the Citizens United ruling, spending by groups not controlled by candidates or party officials has soared. And as the spending has increased, the amount of information about who is funding these ads has decreased.

During the 2010 midterm election, 48 percent of outside spending was carried out by groups that fully disclosed their donors, according to the nonpartisan Center for Responsive Politics. That’s down from about 93 percent during the 2006 election cycle.

The reason? A proliferation of spending by nonprofits organized under section 501(c)(4) or 501(c)(6) of the U.S. tax code. While the nascent super PACs created in the aftermath of the Citizens United ruling are required to disclose their donors who give at least $200, nonprofits don’t have the same requirement. Both super PACs and nonprofits are legally allowed to accept unlimited contributions from individuals, corporations or unions to fund political ads.

Even as more Democrats are pushing for new legislation and regulations to counteract secret election spending, there are plenty of hurdles in the way.

On Tuesday, a three-judge panel of the D.C. Circuit Court of Appeals overturned a recent federal court ruling that campaign finance reformers had cheered. The case, Van Hollen v. Federal Election Commission, is challenging whether groups that run issue ads ahead of an election must disclose their donors — or only donors who give “for the purpose of” funding political advertisements.

The rising levels of non-disclosure helped Dorgan — who is now a senior fellow at the Bipartisan Policy Center think tank and a senior policy advisor at the lobby shop Arent Fox — realize the severity of the situation ahead of the first presidential election in the wake of Citizens United.

“This is the first campaign in which you see the full flowering of Citizens United and how ugly it is,” Dorgan said. “We ignore this at our peril.”

Electronic medical records, long touted by government officials as a critical tool for cutting health care costs, appear to be prompting some doctors and hospitals to bill higher fees to Medicare for treating seniors.

The federal government’s campaign to wire up medicine started under President George W. Bush. But the initiative hit warp drive with a February 2009 decision by Congress and the Obama administration to spend as much as $30 billion in economic stimulus money to help doctors and hospitals buy the equipment needed to convert medical record-keeping from paper files.

In the rush to get the program off the ground, though, federal officials failed to impose strict controls over billing software, despite warnings from several prominent medical fraud authorities. Now that decision could come back to haunt policy makers and taxpayers alike, a Center for Public Integrity investigation has found.

Experts say digital medical records may prove — as promised — to be cost-effective, allowing smoother information sharing that helps cut down on wasteful spending and medical errors.

Yet Medicare regulators also acknowledge they are struggling to rein in a surge of aggressive — and potentially expensive — billing by doctors and hospitals that they have linked, at least anecdotally, to the rapid proliferation of the billing software and electronic medical records. A variety of federal reports and whistleblower suits reflect these concerns.

Regulators may lack the auditing tools to verify the legitimacy of millions of medical bills spit out by computerized records programs, which can create exquisitely detailed patient files with just a few mouse clicks.

“This is a new era for investigators,” said Jennifer Trussell, who directs the investigations unit of the U.S. Department of Health and Human Services Office of Inspector General.

“We are all excited about the many benefits of electronic health records, but we need to be on the lookout for unscrupulous providers who take advantage of this new technology,” she said.

The Center for Public Integrity has recently documented how some health professionals have seemingly manipulated Medicare billing codes to gain higher fees. The investigation unmasked thousands of doctors consistently billing higher-paying treatment codes than their peers, despite little evidence in many cases that they provided more care.

Some of the sharpest surges in more costly coding have occurred in hospital emergency rooms, according to the Center’s data analysis, where billing software has been widely used.

Interviews with hospital administrators, doctors and health information technology professionals confirmed that digital billing gear often prompts higher coding, though many in the medical field argue that they are simply recouping money that they previously failed to collect.

For example, Holy Name Medical Center in Teaneck, N.J., saw a spike in billing codes after wiring up its emergency room in 2007, according to hospital CEO Joe Lemaire.

Coding ‘Slam Dunk’

Electronic medical records can influence pay scales known as “Evaluation and Management” codes. Medicare spent more than $33.5 billion in 2010 using these numeric codes for services ranging from routine doctor office visits to outpatient hospital or nursing home care. More than half the doctors billing Medicare were using electronic records in 2011, and more are expected to follow.

For an office visit, a doctor must choose one of five escalating payment codes that best reflects the amount of time spent with a patient as well as the complexity of the care. The lowest-level code for a minor problem, 99211, pays about $20. But the doctor can bill roughly $100 more for the top level. Hospitals use similar codes for billing emergency room and outpatient services.

The subjective nature of the coding process has left the medical community and those who pay its bills in constant conflict. Many doctors and billing consultants argue that most practitioners habitually charge too little because they neglect to put down on paper all of the work they do, which if done more diligently would justify higher codes and fees.

The HHS Agency for Healthcare Research and Quality, an advocate for pressing ahead with electronic health records, accepted that view when it wrote in September 2009 that doctors may choose billing codes that are too low. The agency suggested that converting to digital systems would enable doctors to bill higher fees, “translating into enhanced revenue.”

By contrast, government auditors and many private insurance investigators see evidence that some doctors pick higher codes to inflate their bills — a practice known in medical circles as “upcoding.”

The rapid expansion of electronic health records is adding a whole new dimension to that quarrel. Government officials, however, have yet to step in and settle whether the hundreds of software products on the market consistently prompt doctors and hospitals to bill at higher levels than they did prior to going electronic — and if the higher fees are merited.

Doctor Backlash

Warnings that digital billing equipment could unleash a torrent of inflated charges date back to the administration of President George W. Bush.

In July 2005, the American Health Information Management Association identified an “unintended incentive for fraud because healthcare organizations and software developers need to prove a return on investment for the coding products,” reads the report, which was commissioned by HHS officials.

Two months later, a second American Health Information Management Association panel stated that “without a deliberative effort to build fraud management” into networks of digital medical records “health care payers and consumers will be exposed to new and potentially increased vulnerability to electronically-enabled healthcare fraud.”

Dr. Donald W. Simborg, a California physician who co-chaired that panel, said its findings were dismissed out of fear that doctors would shun the digital devices if they thought buying one might lead the government to second-guess their fees, and perhaps even accuse them of impropriety.

Simborg also headed up an executive team HHS turned to in 2007 to recommend fraud controls in digital gear certified for sale to doctors and hospitals.

In a May 2007 report, the 23-member group, which included representatives from medical groups, health insurers and government, warned against approving software that assisted doctors in selecting billing codes. It is “not appropriate to suggest to the provider that certain additional data, if entered, would increase the level” of the billing code, according to the report.

“Our report was totally ignored for fear of a physician backlash,” said Simborg. The report saw print under the bland title “Recommended Requirements for Enhancing Data Quality in Electronic Health Records” that gave little hint it dealt with the sensitive fraud issue, he said.

The billing tools that the study panel panned have been trumpeted in recent years by electronic health record manufacturers hoping to persuade doctors and hospitals to shell out thousands of dollars — millions in the case of a hospital — to computerize.

“This is the big elephant right now and we aren’t touching it,” said Simborg.

Dr. Robert Kolodner, a physician who headed the federal push for electronic medical records in 2007, acknowledged that billing abuse took a backseat to steps likely to entice the medical community to embrace the new technology.

Kolodner said officials were certain the savings achieved by computerizing medicine would be so great that billing abuse, “while needing to be monitored, was not something that should be put as the primary issue at that time.”

That view didn’t change much with the 2009 arrival of the Obama team, which was sympathetic to some of the tech companies that stood to benefit handsomely from the conversion.

For instance, giant tech vendor McKesson submitted to the Obama-Biden Transition Team its vision for the rollout, which recommended “significant start-up funds” to get the ball rolling.

Since 2009, the Obama administration has held dozens of public meetings on electronic health record policies and standards, but none that focused primarily on fraud control and billing integrity.

The administration’s Office of National Coordinator for Health Information Technology, which is spearheading the drive, declined to discuss the billing controversy.

But on April 27 of this year that office asked the HHS Office of Inspector General to study the issue. Spokesman Peter Ashkenaz said that ONC “will review any recommendations that are made in the report and will address those at that time.”

Donald White, a spokesman for the inspector general’s office, said that the issue “is on the radar” and the office will be “looking into these codes and how electronic health records may be affecting them.”

But government officials admit they lack a system to monitor the hundreds of billing and medical software packages in use across the country. That shortcoming caught the eye of the American Medical Association, which helped develop the billing codes and favors stricter government standards. In May, the doctors’ group urged officials to require testing that assures digital devices bill accurately and “do not facilitate upcoding.”

‘Improper Payments’

Connecticut doctor Stephen R. Levinson, who authored a major textbook on medical coding published by the AMA, strongly believes that many electronic medical records systems improperly raise coding levels.

He said the units are programmed to easily allow doctors to cut and paste records from prior encounters with a patient so that “records of every visit read almost word for word the same except for minor variations confined almost exclusively to the chief complaint.”

That extra documentation often triggers the software to raise the billing level and the size of the patient’s bill. But Levinson said information from previous visits is often not “medically necessary” to treat a current problem — and thus not a legitimate factor in charges.

Levinson said “cloned documentation” in a patient’s file often “doesn’t make sense clinically,” but it steps up billing and rewards the doctors with a “slam dunk” higher billing level, even though it takes 30 seconds to copy and paste.

“This is done in the wrong way and doesn’t satisfy the patient’s needs,” he said.

These “cut and paste” features produce voluminous files that are difficult for auditors to challenge, even when they suspect that the doctor did very little to warrant the higher fees.

That’s starting to change, however, greatly raising the stakes for doctors and hospitals that could face a demand for repayment from the government on behalf of patients.

Insurance auditors criticized “over documentation” as a billing ploy as far back as 2006. That year Medicare contractor First Coast Service Options chided Connecticut doctors who “frequently over-documented” to justify higher billing codes.

The Department of Health and Human Services Office of Inspector General late last year announced it would ratchet up audits of  “potentially improper payments” linked to electronic medical records. The office also advised doctors they could be held accountable if the codes they used didn’t “accurately reflect the services they provide.”

Electronic health records figured prominently in a critical Medicare audit of Texas and Oklahoma hospital emergency rooms in March. The audit concluded that $45.14 of every $100 billed for emergency room care “was paid in error.”

Auditors said that billing codes were “higher than was reasonable and necessary to adequately care for the patient’s needs or treat the presenting problem.”

One unidentified hospital billed Medicare for the highest level code, 99285, for treating a woman who arrived at the emergency room complaining of mild to moderate abdominal pain. The code is generally reserved for conditions of “high severity” that “pose an immediate significant threat to life and limb,” auditors wrote.

After a battery of tests, including a CT scan, and intravenous antibiotics and morphine, the doctor diagnosed a urinary tract infection, sent the woman home and told her to follow up with her regular doctor.

Auditors said the woman’s case should have been coded two rungs lower based on the degree of medical decision-making required.

They also criticized the electronic record system for generating “testis and penile assessment findings” for a female, noting “coding at a higher level based on clinically unnecessary (or anatomically incorrect) systems examined is not acceptable.”

Hospitals have faced scrutiny over their use of electronic billing in emergency rooms from other quarters as well.

Dr. Alan Gravett, an Illinois emergency physician, argues in a federal “whistleblower” lawsuit that hospitals have jacked up emergency room bills with the help of aggressive billing software.

The doctor filed suit under seal in the U.S. District Court for Northern Illinois in January 2007. He alleges Methodist Medical Center in Peoria, Ill., where he worked for six years, installed a McKesson Corporation digital records system in March 2006 “specifically to increase its billings and recovery from government funded health insurance programs.”

Gravett alleges that the billing system had a “tendency to inflate nearly every” emergency room code. This happened “despite the physicians’ belief that lower … codes were warranted based on the degree of care they provided,” according to the suit.

The lawsuit alleged that patients who were treated in the emergency room for many seemingly simple conditions were “as a matter of course” coded at high levels. The diagnoses included toe injury, sprained ankle and toothache.

The software, according to Gravett, prompted charges for conditions such as “alcoholic intoxication” or “psychiatric cases” to a code four or five, “even when such patients are treated and released, or released with no treatment.”

The screen also prompts doctors to add documentation to reach a higher coding level, according to Gravett’s court filings.

To pressure doctors to go along, the hospital distributed a monthly report called a “lost charge analysis,” which ranked doctors by how much revenue they produced, according to the suit.

“This was done to pressure the physicians to out-bill one another, and weed out physicians that were not generating as much income as those willing to upcode,” according to the court filing.

Methodist hospital spokesman Duane Funk said the hospital has yet to be served with the suit and would have no comment. McKesson did not respond to requests for comment.

A second “whistleblower” lawsuit filed in the state of Washington in 2006 alleged that Health Management Associates, a Florida-based hospital chain, used software called Pro-Med Clinical Systems that prompted questionable billing.

The suit was brought by two emergency room physicians at one of the company’s hospitals, Yakima Regional Medical and Heart Center. The doctors alleged that using Pro-Med led to “misleading medical charts,” including “examinations which had not occurred and physical observations which had not been noted by the physician.”

The software “automatically ordered a series of expensive and unnecessary tests,” according to the suit, which was dismissed in February 2009.

Pro-Med, based in Coral Springs, Fla., was not named as a defendant. Pro-Med CEO Thomas Grossjung said the hospital, not the software company, set the treatment protocols.

Maryann Hodge, vice president of marketing for Health Management Associates, said the hospital chain was never served with a copy of the suit, though it had cooperated with federal officials investigating the matter.

The hospital chain’s use of Pro-Med has come under review in a more recent federal investigation of emergency room billing, records show.

Health Management Associates, which owns or leases more than 60 hospitals in 15 states, disclosed in a May Securities and Exchange Commission filing that the HHS inspector general’s office was investigating it’s business operations, including whether “Pro-Med software has led to any medically unnecessary tests or admissions.” Hodge said the company could not comment further on the investigation.

A second hospital chain that has used Pro-Med also has been served with a subpoena from federal investigators.

Community Health Systems, Inc., which owns and operates some 130 hospitals in more than two-dozen states, told investors in April 2011 that HHS was investigating “possible improper claims.” The subpoena requested documents concerning use of the Pro-Med software in emergency rooms, according to the SEC filing. Tomi Galin, Community Health Systems’ vice-president for corporate communications, said at the chain's hospitals the software does not order tests or “make any recommendation to physicians about whether to admit patients, place patients in observation or discharge patients.”

Both hospital chains said in SEC filings that they are cooperating with investigators. Pro-Med CEO Grossjung said his firm also had met with federal investigators, but the probe had “nothing to do with the software itself.”

Doctors’ groups also are reporting higher fees associated with electronic records, though they argue that the systems merely allow them to catch up with billing practices that for years did not pay them enough.

Robert Tennant, a Washington lobbyist with the Medical Group Management Association, which represents large medical practices, said the software simply helps doctors pick the correct code. “With a paper based system there’s a little bit of concern from providers that they don’t have sufficient documentation to support a particular” coding level, he said. Electronic systems, however, can quickly retrieve a patient’s documented history.

“I don’t use the term ‘upcode.’ I use ‘correct code.’ I see it more as physicians being reimbursed more appropriately for the work that they’re doing,” he said.

After the Gold Rush

Judging from their marketing strategies, there’s little doubt among the makers of electronic health records that their products will pay for themselves — and then some — through higher coding of patient bills.

Sales literature touts features such as “charge capture,” highlighting the computer’s skill at never missing a billable item that a human might overlook.

Many companies stress that the software can pay for itself through more lucrative codes, a benefit called “ROI,” short for return on investment. That pitch suggests a doctor who collects stimulus payments over time will cover the purchase costs and eventually turn a nice profit as a result of higher fees from higher coding.

For instance, one manufacturer predicts a rise of one coding level for each patient visit, which it said could add up to $225,000 over the course of a year. Another cites a medical journal report that a medical practice in Utah “produced an average billable gain of $26 per patient visit.” 

Ross Koppel, a sociology professor at the University of Pennsylvania who has studied design weaknesses in the software, said that sales agents stress how the machines help doctors document the work they do.

“That presumably is fair and good, but everybody knows there is a ‘wink, wink’ behind that indicating it will help … make the patient’s visit look more involved than it is.” That “generates additional revenue” for doctors, Koppel said.

The industry’s trade association, the Healthcare Information and Management Systems Society, has published a guide for doctors to use in estimating how much new revenue they can expect by going electronic. It cites as one key benefit, “increased coding due to elimination of lost charges and using appropriate coding levels based on services delivered.”

But some others note that doctors may initially lose money from wiring up their practices, mainly due to the time it takes them and their staffs to learn how to use the equipment and its high upfront cost.

‘Unintended Consequences’

The emphasis on improving the bottom line, rather than the quality of medical care, has disappointed some longtime health policy hands.

The Obama administration’s foray into digital medicine “has backfired at this point,” said Dr. Robert Berenson, a former vice chairman of MedPac, a commission that advises Congress on Medicare payment issues.

Berenson said that the current crop of electronic medical records encourage too much medical documentation “for the purposes of billing” and not better patient care.

The software helps doctors submit bills for “a higher level code than was performed,” said Berenson, who served as a member of the 2008 Obama transition team on health policy. “It’s a lot of money and the money goes right to the bottom line,” he said.

The criticisms are not just about money. The American College of Physicians, which represents more than 100,000 internists, considered the threat to patient safety serious enough that in May it announced a class for doctors in “potential problems associated with the use” of electronic medical records and “strategies to overcome these problems.”

Some doctors grumble about slogging through pages of redundant information that appears to be in a patient’s file simply to satisfy requirements for stepped up billing codes.

Just like in the days of poor physician handwriting, the voluminous computer generated files can prove tough for doctors to quickly decipher and decide how to treat a patient’s illness.

“We’re getting a whole generation of records that are not illegible, they are largely un-interpretable. It’s a horrific problem,” said Dr. Bob Elson, a former health information technology specialist, now a physician at the Cleveland Clinic.

These criticisms aside, many in the medical community regard the switchover not only as inevitable, but also as an opportunity to revolutionize medicine. For starters, researchers hope to be able to mine data from millions of patients to discover better ways to treat disease and improve the nation’s overall health.

The initiative continues to pick up speed behind a broad coalition of political players, from an elite corps of technology experts to organized labor groups that support moving medicine into the 21st century with dispatch.

Tennant, whose group represents medical practices, noted that Congress and the Obama administration have sent a “clear message” that they want physicians to adopt electronic health records.

He said “a slight uptick” in codes would be more than offset by savings on duplicative tests and other waste associated with paper records systems, and by higher quality care.

So far, the government has shelled out about $5 billion in incentive payments to doctors and hospitals that have adopted the technology, according to the Government Accounting Office.

How much Medicare has paid out in higher codes related to digital billing is trickier to assess. In 2011, 57% of Medicare doctors were using an electronic health record, most for three years or less, according to an HHS survey. Officials expect those numbers to climb as doctors scramble to avoid Medicare payment cuts to those who fail to adopt the technology starting in 2015.

But Elson, the Cleveland clinic doctor, said that government officials may have oversold the benefits to Congress by failing to account for health care costs to rise from higher coding, at least in the short term.

“That’s a huge oversight if that whole issue wasn’t factored into the strategy,” Elson said.

UDDANAM, India — A tangle of green blankets the land amid thick tropical heat. Shady groves of cashew trees strew the ground with juicy, perfume-scented fruits. Men can be seen climbing coconut palms to tap into the trunks for wine. The region’s name, Uddanam, comes from a word in Sanskrit that means “Beautiful Garden” or “Paradise.”

Uddanam’s rich terrain seems an unlikely place for the mysterious strain of illness tormenting the area. For more than a decade, a rash of chronic kidney disease has been striking down the villagers of this remote agricultural belt in the state of Andhra Pradesh, India. In some villages, the disease has impacted from 24 to 37 percent of the population, two to three times higher than elsewhere in the district, according to unpublished results from a study by Harvard Medical School.

As the death toll mounts, the seemingly idyllic region has become stigmatized. In contrast to Nicaragua’s “Island of the Widows,” which is named for the alarming rate of chronic kidney deaths among the community’s husbands, residents of Uddanam say they now have trouble getting married at all.

“Other people, they don’t want to come for marriage,” said Dr. Priya Prathibha, the state medical officer in the hard-hit village of Varaka. “They are not giving any bride or bridegroom to this area, this Uddanam area.”

Uddanam’s victims have much in common with those of the unexplained epidemics in Sri Lanka and Central America. They come from farming communities and are mostly poor. Few suffer from diabetes or hypertension. The climate is sweltering, toxic pesticides are used liberally, and biopsies show the rare pattern of tubulo-interstitial kidney damage. This type of damage accounts for less than 4 percent of end-stage renal disease in the United States, and is consistent with severe dehydration and toxic poisoning.

Yet in other ways Uddanam is different. The research to date suggests the disease is confined to a single belt of villages that spans less than 100 miles. Despite men’s traditional role in the fields, both sexes are affected almost equally, teams from Harvard and Stony Brook University found. Farmers of several different types of crops — coconuts, cashews and rice — are all affected.

The known impact is also smaller: from 2007 to 2012, a total of 1,520 people required treatment for kidney disease through the state health program. Even if several times as many are in the latent early stages of the disease, its geographic and humanitarian scope is more contained than in Central America or Sri Lanka.

“Our hypothesis is that an exposure to something in the environment, whether it’s in the soil or in the water or both, is responsible for this,” said Dr. Ajay Singh, a nephrologist at Harvard Medical School and the co-leader of the Harvard study.

The research has yet to offer definitive answers. Not a single study has been published on Uddanam CKD, nor do any official statistics measure its scale or reach. Among the scientists and the villagers, confusion and frustration reign.

“They come to you and they don’t understand what’s happening to them,” Singh said of Uddanam’s residents. “But they do understand that they’re dying from the disease and there are no resources to help them out and something needs to happen there.”

A Family Tragedy

Hyamavathi and Prameela Bendalam have lived the tragedy that has left many Uddanam families frightened of consenting to marriages. Both were in their early twenties when they married and moved to a village in the region called Varaka. Hyamavathi was about 23 when she married her husband, a coconut and rice farmer named Venkataramana Bendalam, in 1990. Prameela was about 20 when she married Venkataramana’s brother Rama Rao, also a rice farmer.

The marriages made the women “co-sisters,” and they began living together in the Bendalam family compound. For more than a decade, their husbands worked the five acres of rice paddy and coconut fields owned by the family.

In 2005, their husbands began to experience difficulty urinating. Both were initially diagnosed with urinary tract infections before traveling to visit doctors in Visakhapatnam, also known as “Vizag,” a city more than 100 miles away.

“They were unwell, but we didn’t know a disease had hit,” Prameela said. “Then we found out that they had kidney condition, when we went to Vizag.”

The illness left the two brothers feverish and nauseous, and eventually too sick to work. Both took medicines to relieve the disease’s symptoms, but the family could not afford dialysis. Prameela said the cost of the treatment her husband did receive was more than 60,000 rupees, close to $1,100 at the current exchange rate.

The family had to take out loans, and then to gradually sell off their land. Prameela and Hyamavathi took care of the two terminally ill brothers. “The both of us were in a lot of pain and misery,” Prameela said.

In 2007, Venkataramana and Rama Rao died less than a month apart — on November 25 and December 23, respectively.

Prameela and Hyamavathi remain in the compound, and now work the single acre that remains of the land cultivated by their husbands. This labor provides their only income beside the thousand rupees (roughly $18) each month that Prameela’s son Siva earns as a teacher in a private institute.

“I borrowed money thinking that he would survive,” Prameela said of her husband. “But he died, and now the loans have to be paid back as well. This is bad karma, full of suffering.”

Since their deaths, the state government of Andhra Pradesh has established new programs that assist Uddanam’s victims. A statewide health insurance program for the poor now covers the costs of dialysis. State-of-the-art dialysis centers have been established in several cities through a public-private initiative led by Dr. Ravi Raju Tatapudi, a leading nephrologist who served three years as Andhra Pradesh’s director of medical education.

But almost all of the area’s nephrology and dialysis services are in Vizag. The costs of travel and of medicines that are not covered by the insurance program are still prohibitive for many families in Uddanam.

“They have dialysis but they are 200 kilometers away,” said Sham Sundar Puriya, the village head in Patha-Varaka, a sub-community in Varaka village. The residents “cannot go to that place because of lack of money, so they are staying here and dying here.”

Uddanam lacks doctors. There are no full time nephrologists stationed within 100 miles of the region, and local medical officers must refer their patients to distant urban facilities. Dr. Prathibha, the medical officer who lives in Varaka, says the fear surrounding the disease has left “even doctors” scared to live in Uddanam.

“If they are not coming,” she asked, “who will?”

Frustration and Fear

Since the 1990s, when Tatapudi and other nephrologists began noticing the unusual strain of CKD in Uddanam, various theories of the disease’s origins have emerged. Most have centered on toxic exposure. An unpublished study by a team of researchers from Uddanam and Stony Brook University concluded that the disease is “most likely to be the result of a chronic exposure to an environmental agent.”

Dehydration, another possible factor, has received less attention. The Uddanam area is brutally hot, and farmers spend long hours in the fields.

Dr. Goru Krishna Babu, a researcher who conducted door-to-door surveys in Uddanam for the Harvard study and grew up nearby in Andhra Pradesh, said the heat was so overwhelming one day, he had to stop and lie down while carrying out the surveys. “One of the things I took pride in was that whatever the temperature was I could sustain myself,” he said. “But one of the days I literally had to lie down on the bed.”

So far, the efforts of the Stony Brook, Harvard and state government researchers remain tied up in delay. None have published studies that point toward specific suspects. A lab test by Stony Brook that tested local water for contamination by any of 42 toxic chemicals, including heavy metals such as arsenic and cadmium, revealed nothing out of the ordinary, said Kate Dickman, a pharmacologist with the Stony Brook team.

The most visible sentiment in Uddanam is frustration: that the years of research and promises haven’t brought results. As the deaths continue, many residents have become fearful of living in a land so beautiful it was named after “Paradise.”

“So many people are leaving,” said Siva Bendalam, Prameela’s 20-year-old son who helps support his family. “If the disease continues, no one will be here.”