More on Diabetes

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The US is seeing modest, steady growth in the incidence of diabetes among children and teens. A new analysis of data from 2012 to 2012 shows

  • An increase in Type 1 Diabetes of 1.8% per year and
  • An increase in Type 2 Diabetes of 4.8% per year.

While there’s a genetic component, diabetes risk is associated with

  • Family history
  • Immune system issues
  • Diet and weight (and exercise)
  • Blood pressure

Europeans understand that how you care for yourself affects health care costs and health insurance rates for everyone around you. It’s not just about you. Teaching a child to veg in front of a computer or TV simply shortens the child’s life.

However, one of the frustrations with public health data is lack of currency. Has the situation gotten better or worse in the last five years?  My guess is worse, but we simply don’t know.


Sources:

  1. Elizabeth J. Mayer-Davis, Jean M. Lawrence, Dana Dabelea, Jasmin Divers, Scott Isom, Lawrence Dolan, Giuseppina Imperatore, Barbara Linder, Santica Marcovina, David J. Pettitt, Catherine Pihoker, Sharon Saydah, Lynne Wagenknecht. Incidence Trends of Type 1 and Type 2 Diabetes among Youths, 2002–2012. New England Journal of Medicine, 2017; 376 (15): 1419 DOI: 10.1056/NEJMoa1610187
  2. NIH/National Institute of Diabetes and Digestive and Kidney Diseases. “Rates of new diagnosed cases of type 1 and 2 diabetes on the rise among children, teens: Fastest rise seen among racial/ethnic minority groups.” ScienceDaily. ScienceDaily, 14 April 2017. <www.sciencedaily.com/releases/2017/04/170414105821.htm>.
  3. International Diabetes Foundation, “Risk Factors.” http://www.idf.org/about-diabetes/risk-factors
  4. Mayo Clinic, “Diabetes.” http://www.mayoclinic.org/diseases-conditions/diabetes/basics/risk-factors/con-20033091

Salt, Food, Sleep, Health and Taxes

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largeThere have been a number of articles relating salt and urination. The more salt you ingest, the more urine you produce.  Simple.

Now a Japanese study relates salt consumption to waking in the middle of the night to use the toilet. More salt means more trips to the bathroom at night.(1)

Salt affects blood pressure, and that in turn contributes to heart disease and stroke..  According to the American Heart Association, on average, Americans eat more than 3,400 milligrams of sodium each day.(3)

  • The recommended consumption amount is 1,500 mgs. per day for most adults, so this is more than double the recommended amount. Either too much or too little can be a problem. 
  • The maximum “safe” consumption is 2,400 mgs. per day.  The average American is way over the limit.
  • Most salt comes from processed foods such deli meats and canned soups. It’s important to read the labels and know what you are eating.

The British National Health Service estimates that salt reduction would result in 14,000 fewer deaths per year, at a savings of more than £3 billion.  The savings to Americans would be proportionally greater.

  • Converted to US dollars, the British cost savings is greater than the annual deficit reduction the recently deceased healthcare reform bill was supposed to produce.

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NOTE: There are contrarians who argue that concerns with salt consumption are a “myth.” I read one by Kris Gunnars, who claims to use an “evidence-based” approach. However, there is a complete lack of data in his argument; it reads like wishful thinking. My strong preference is for experimental designs using test and control groups rather than theory.

If you want to ignore facts, that’s your choice. However, you should know what you are doing and accept responsibility for the consequences of your actions. Making up “alternative facts” to justify your choice isn’t acceptable.

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What you need to consider:

  • What you eat can affect your quality of life, your health care and health insurance costs, and even your taxes.
  • However, this is one of those issues that requires large numbers of people to change behavior to make a difference. You need to mobilize your family and friends.

 


Sources:

  1. Sarah Knapton, “Cutting salt intake could stop excessive toilet trips in the wee small hours,” The Telegraph, 26 March 2017. http://www.telegraph.co.uk/science/2017/03/26/cutting-salt-intake-could-stop-excessive-toilet-trips-wee-small/
  2. American Heart Association, “What should my daily sodium intake be?” https://sodiumbreakup.heart.org/how_much_sodium_should_i_eat?utm_source=SRI&utm_medium=HeartOrg&utm_term=Website&utm_content=SodiumAndSalt&utm_campaign=SodiumBreakup
  3. American Heart Association, “Sodium and Salt.” http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/HealthyDietGoals/Sodium-Salt-or-Sodium-Chloride_UCM_303290_Article.jsp?gclid=CIbzu9fO9NICFYOKswodxbgPdw#.WNf0OKKVtPZ
  4. Kris Gunnars, “The Salt Myth – How Much Sodium Should You Eat Per Day?” https://authoritynutrition.com/how-much-sodium-per-day/
  5. Centers for Disease Control and Prevention, “Most Americans Should Consume Less Sodium.”  https://www.cdc.gov/salt/

Healthcare Repeal: Where we are tonight (23 March 2017)

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17456_1269532813224_1076952025_30803996_7657050_nThe GOP House bill has emerged and it’s designed to hurt most Americans. The House committees involved are rushing to vote on this before the nonpartisan Congressional Budget Office (CBO) can weigh in on costs or impact. There’s a reason.

 

The bill keeps three elements of the Affordable Care Act:

  • Insurance companies can’t deny coverage based on pre-existing conditions.
  • No lifetime cap on benefits.
  • People can stay on parents’ coverage until age 26.

That’s the good news.

The good news for those with high incomes:

  • Tax credits for buying health insurance.
  • Elimination of health insurance related taxes on people with high incomes.
  • No requirement for having health insurance.
  • No tax penalties for not having it.
  • Double the amount they could contribute to Health Savings Accounts (tax benefit).

The bad news:

  • Large employers would no longer be required to offer health insurance.
  • A 30% rate increase is your health insurance lapses.
  • Income tax credits for health insurance based on income are replaced by smaller tax credits based primarily on age and family size. The amount of these credits would be reduced for individuals making more than $75,000 per year or couples making more than $150,000, but even the affluent would receive credits.
    • The credits range from $2,000 to $4,000 per person, with a cap of $14,000 for a family.
  • Rate increases:  According the the nonpartisan Congressional Budget Office, the cost for individual insurance will increase by between 15% and 20% for each of 2018, 2019 and 2020.
  • The special hit for those over 50:  The price range by age will increase from a factor of 3 to a factor of 5.  Under the ACA, people between the ages of 50 and 60 could be charged no more than 3 times what a healthy 20 year old would be charged.  Uncer the bill that changes to a multiplier of 5.  Assuming a 20-something pays roughly $300 for health insurance, here’s the math:
    • Under the ACA. a 60-year-old faced a monthly cost of $900 before subsidy, which could be as much as $500. That’s a net cost of $400 per month.
    • Under the new rules, with a conservative 18% base rate increase, the cost for a 60-year-old would be $1,770 per month, with a maximum subsidy of roughly $330. That’s a net cost of $1,440 per month.
  • The Medicaid rollback.  Obama extended Medicaid to those who couldn’t afford health insurance; the current bill reverses that, leaving up to 24 million with no health insurance coverage.
  • Reduced cancer screening:  Elimination of funding for Planned Parenthood — which impacts cancer screening for less affluent women.

The bill creates a huge financial burden for Americans.  To put this in context, median weekly income for American workers is $849 (2016, Bureau of Labor Statistics). With deductibles and copays, more than one week of each month’s earnings would go to healthcare. For some Americans in the 50+ age group (pre-Medicare), the cost of health care could approach half of monthly take home.

We have to say “could” because the final rates for health policies for 2018 haven’t been approved by state insurance commissioners yet.  However, the CBO estimates are in line with the increases the insurance industry has said it will request.

That’s a huge dent into household budgets, and into consumer spending for other products and services. So much for economic growth.

The CBO is required by law to assess the economic impact of major legislation. However, backers are trying to rush this bill through Congress before the CBO has time to complete this analysis.(6)

As stated in other posts, part of the purpose of the Affordable Care Act was to allow for early detection of disease and reduced reliance on ER services for healthcare.  Both of those goals would actually reduce total spending on healthcare.  The GOP bill largely undoes both of these.

The mixed news:

  • The elimination of requirement that everyone have healthcare means that the “risk pool” for calculating rates will be smaller, and the cost per person will be higher.
  • The bill would give block grants to the states that could be used to help consumers pay for health insurance. But that would be up to state legislatures.

 

At this writing, the fate of the bill is uncertain.  Some extremists want the elimination of any government support for healthcare for Americans.  For them, the current bill offers too much to consumers.  The AARP has gone to war because of who the bill will impact people over age 50. GOP congressmen who are worried about re-election are nervous about supporting this bill.  Seniors are much higher rates of voting than other Americans and can swing close elections.  The vote on the bill in the House has been postponed as backers don’t have enough votes to pass it.

To gain additional support, the bill was changed this week to add more tax benefits for the wealthy.

Even if the bill passes the House, the ability to get it through the Senate is questionable.

Apart from extreme conservatives, opponents to the bill include:

  • The AARP.
  • The AMA and all other associations of medical professionals.
  • Hospitals and clinics, who don’t want and can’t afford an influx of clients without insurance.
  • Democrats who don’t want to see people lose coverage.

Four Senate Republicans have voiced opposition to the Medicaid rollback.

“We will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states,” Sens. Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) wrote in a letter to Senate Majority Leader Mitch McConnell (R-Ky.).

The bill will raise health insurance costs for most Americans.

One senior Republican suggested that under his party’s bill, Americans would have to pay a larger share of their own health care costs.

“Americans have choices, and they’ve got to make a choice,” Representative Jason Chaffetz of Utah, the chairman of the Oversight Committee, said on CNN Tuesday. “So rather than getting that new iPhone that they just love and want to go spend hundreds of dollars on that, maybe they should invest in their own health care.” (4)

This is as close to the infamous Marie Antonette quote, “Let them eat cake,” as we have ever seen in American politics.

What you need to remember

  • Insurance policies/contracts for 2017 will be unaffected. 
  • However, if you let policies lapse this year, that may affect what you pay in 2018, by a lot.

Sources:

  1. Robert Pear and Thomas Kaplan, “House Republicans Unveil Plan to Replace Health Law,” The New York Times, 6 March 2017.
  2. House Republicans release long-awaited plan to replace Obamacare,” The Washington Post, 6 March 2017. https://www.washingtonpost.com/powerpost/new-details-emerge-on-gop-plans-to-repeal-and-replace-obamacare/2017/03/06/04751e3e-028f-11e7-ad5b-d22680e18d10_story.html
  3. FoxNews, “House Republicans release long-awaited ObamaCare replacement bill,” 6 March 2017. http://www.foxnews.com/politics/2017/03/06/house-republicans-release-obamacare-replacement-bill.html
  4. Zachary Tracer, Anna Edney, and Steven Dennis, “Aiming to bridge gaps within the party, GOP releases health care reform details,” BenefitsPro, 7 arch 2017.  http://www.benefitspro.com/2017/03/07/aiming-to-bridge-gaps-within-the-party-gop-release?kw=GOP+releases+health+care+reform+details&et=editorial&Zbu=BenefitsPRO&cn=20170307&src=EMC-Email_editorial&pt=News+Alert&t=wellness&page=2
  5. Robert Lowes, “House Releases ACA Repeal, Replace Bill That Transforms Medicaid,” Medscape, 8 March 2017. http://www.medscape.com/viewarticle/876718
  6. Congressional Budget Office, “American Health Care Act,” 13 March 2017. https://www.cbo.gov/publication/52486

Fetal Alcohol Syndrome: Shouldn’t We Know Better?

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Fetal Alcohol Spectrum Disorders (FASD) encompasses a range of issues in a newborn that map1-anyuse-and-bingeresults from alcohol use by the mother.  The range of symptoms include:

  • Abnormal facial features, such as a smooth ridge between the nose and upper lip (this ridge is called the philtrum)
  • Small head size
  • Shorter-than-average height
  • Low body weight
  • Poor coordination
  • Attention deficit and/or hyperactive behavior
  • Poor memory
  • Learning disabilities
  • Poor reasoning and judgment skills
  • Sleep and sucking problems as a baby
  • Vision or hearing problems
  • Problems with the heart, kidneys, or bones

Lancet has published an estimate of 119,000 new cases of children born with FAS each year globally ( rate of between 6 and 14 cases per 10,000 newborns). The map below shows incidence by country, with Russia and Australia being hot spots.

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However, the CDC has suggested that as many as 2% to 5% of births in the US are affected by FAS.

Examination of medical records produces the lowest estimates of FASD.  Community studies based on physical examinations of children produce much higher estimates.

The message is simple, but apparently hard for some to accept:  if you’re pregnant, don’t drink.

This discussion also ties into the current conversation about restricting abortions:  If you know a fetus has severe defects, whatever the cause, what’s the right thing to do?


Sources:

  • Centers for Disease Control and Prevention, “Fetal Alcohol Spectrum Disorders (FASDs)”.  https://www.cdc.gov/ncbddd/fasd/facts.html
  • Popova, Svetlana et al., “Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis,” The Lancet Global Health, rev. 25 January 2017.  http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30021-9/fulltext

Healthcare: what you do need to do

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Donald Trump promised today that there will be “healthcare for everyone” after repeal of the ACA.ben_franklin

He can actually do that very easily and cheaply, by cutting back the healthcare provided to “catastrophic” coverage.  This category of plan exists today, but almost no one actively sells it because if provides very little value to the consumer.

Currently, these plans are for people who are under age 30 and those who have hardship exemptions from the ACA requirement for having health insurance coverage.  The plans are required to provide coverage for up to 3 visits with a primary care physician and 5 other basic services.  The plans have very high deductibles — $6,850 currently — and the consumer is responsible for 100% of all other charges before the plan will contribute anything.  On the plus side, these plans are cheap, costing less than $50 per month.  That’s because so few people actually get any benefit from them.

Thus, to take care of yourself, you need to have $6,850 or more in ready cash or a rich relative who’s willing to spot you the money.  With a family, you need more.  If your health goes south, using home equity to pay these expenses puts you at risk of losing your home.  Using other credit could put you at risk for bankruptcy.  (Medical bills remain the leading cause of bankruptcy in the US.)

Several analysts have indicated that the trend for both general healthcare and Medicare will be for the government to pay for less and consumers to pick up the bill for more.  The idea that the ACA will be replaced by more limited coverage fits with this trend.

What you need to do:  Stop spending and save your cash.  You’re going to need it, one way or another.  This applies to everyone, including those on Medicare.  The goal should be a “war chest” the equivalent of at least six months of income — and a lot more if you have kids.  You need to build that as quickly as possible.  If it sounds daunting, it can be done.  As Churchill said about the need to work with Stalin in WWII, “you can walk with the devil until you get over the bridge.”

Unfortunately, if enough people follow this advice, we will slide right back into a recession — which is another reason for growing that war chest.

Ben Franklin was right:  “a penny saved really is a penny earned.”

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Sources

What’s Best for the Patient?

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[Note: in all of my writing, I try to place personal opinion in blue italic font to separate it from what I am reporting from other sources.]

doctor-clip-art-doctor-clip-art-4There are a number of factors that can affect decisions that doctors make about patient care. What’s “objectively best” for the patient may be only one consideration.  Patients need to know this.  While you may not be a doctor, you bear the ultimate responsibility for your own care.  You’re the one who has to live with the results.

 

Recent articles point to some of the issues that can impact treatment:

  • Doctor revenue.  Doctors can (and a few have been accused of this) maximize revenue by ordering unnecessary tests and performing unnecessary procedures.
    • A common example in the literature is the use of CT, MRI or X-ray in the first 30 days after reporting lower back pain.  Other systems besides back pain may require these test, but for lower back pain alone, no.
      • “One study found that people who got an MRI during the first month of their back pain were eight times more likely to have surgery than those who didn’t have an MRI — but they didn’t get relief any faster.” [Agnvall]
    • 61 doctors were among 301 people criminally charged earlier in 2016 with billing Medicare for care and prescriptions that weren’t medically necessary.
    • One of the current curiosities concerns rotator cuff surgery
      • Outpatient rotator cuff surgeries have increased by 272% in the last 5 years.  (Are we really that much more active??)
      • Rates of post surgery problems vary between surgery facilities from a low of 1/2% to 20%.  (If you need the work, are you having it done by the right doc?)
  • Measurements used in the current Federal “pay for performance” initiative.  “Pay for performance” is an effort to reward doctors and hospitals that delivery high quality care and penalize those that don’t.  The metrics include patient satisfaction questions, and some doctors argue that inclusion of those questions might cause doctors to cater more to what patients want than what is medically necessary.
    • That in turn raises two questions
      1. If docs pay more attention to what patients are saying, is that a bad thing?
      2. This criticism by surgeons seems similar to the complaints some teachers have about standardized testing.  In both situations, would the absence of any metrics make the situation better?
  • What insurance will cover, of course.
    • However, a dedicated physician can encourage the insurer to do the right thing.
    • My wife was injured, and the doctor felt she required a treatment the insurer was unwilling to approve.  His reaction was to hospitalize her (for which the insurer was committed to pay) until the insurer agreed to the treatment.  It worked.

What you need to do:

  • Learn how to search for information on your medical symptoms before you consult with a medical professional.  Be an informed patient.  If you don’t know, ask someone for help.
  • Prepare intelligent questions for your conversation with the doctor.
  • If tests are recommended, ask what they will accomplish.
  • If surgery is discussed, consult another doctor from a different medical practice who is unknown to the first doctor.  Conflicts of interest can be a problem, and you don’t want to go there.

Sources:

  1. Agnvall, Elizabeth, “10 Test to Avoid,” AARP Bulletin, 3 December 2015.  http://www.aarp.org/health/conditions-treatments/info-2014/choosing-wisely-medical-tests-to-avoid.html
  2. Cohen, Jessica Kim, “Outpatient rotator cuff repairs increase 272% in a decade — 5 facts on orthopedics in ASCs,” Becker’s ACS Review, 4 January 2017.  http://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/outpatient-rotator-cuff-repairs-increase-272-in-a-decade-5-facts-on-orthopedics-in-ascs.html
  3. Frelick, Marcia, “Current Measures Flawed, Could Cause Problems, Surgeons Say,” Medscape.com, 6 January 2016.
  4. Gawande, Atul, “Overkill”, The New Yorker, 11 May 2015.  http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
  5. Haelle, Tara “Putting Tests to the Test: Many Medical Procedures Prove Unnecessary—and Risky,” Scientific American, 5 March 2013.  https://www.scientificamerican.com/article/medical-procedures-prove-unnecessary/
  6. Sandhu, Sarina, “40 common treatments and tests that doctors say aren’t necessary,” iNews, 24 October 2016.  https://inews.co.uk/essentials/news/health/40-treatments-doctors-saying-bring-little-benefit/
  7. Sun-Times Wire, “Skokie, Buffalo Grove doctors charged in Medicare fraud sweep,” Chicago Sun-Times, 23 June 2016.  http://chicago.suntimes.com/news/2-suburban-doctors-charged-with-medicare-fraud/

Financial Insecurity Revisited

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Thomas Jefferson in the Declaration of Independence wrote that citizens are entitled to “Life, Liberty and the Pursuit of Happiness”.

How is that possible without basic necessities, including food, housing and health?

Three programs are going to be under siege this year:  The Affordable Healthcare Act, Medicare and Social Security.  The goal of reformers, intentional or not, will be to make healthcare unaffordable for millions of Americans.

The US is already the only industrialized nation in which life expectancy is correlated with wealth.  Life expectancy is 88 for the wealthy, and 72 for poor males.

Watch this space, as I will provide details about the reform proposals that won’t appear in the mass media.  As usual, I will document carefully my sources, so that you can draw your own conclusions based on the data.

I’m very concerned.