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Category: Aging

The Affordable Care Act: Moving the Public Closer to “Medicare for All”?

By Mark A. Kelley, MD |8/30/17
Founder, HealthWeb Navigator

The Affordable Care Act (ACA) debate resumes when Congress returns from its summer recess on September 4th. In the meantime, the debate has already had major effects on public opinion.

A recent report describes how Americans currently view the ACA. According to national polls, over 90% of Americans would change the current law. Most Democrats would expand ACA coverage while most Republicans would reduce ACA benefits or rewrite the law completely. Only 8% of those polled would repeal the ACA without a replacement.

The most surprising result is the public’s response to the following statement: “It is the responsibility of the federal government to ensure that all Americans have health coverage.”

Last year, 51% of Americans agreed with that statement. In 2017, the approval rate jumped to 60%. It appears that a government health insurance option is gaining popularity.

Meanwhile, contrary to some reports, the ACA program is stable. Most regions of the country still have private insurance plans available through the ACA. Many insurers increased premiums to cover losses, but that one-time intervention seems to have stabilized the markets.

The reality of health insurance is that it must be profitable to cover unexpected losses. The insurance company has several tools to ensure a profit: charge high premiums, select consumers with low risk, or limit the services and/or payments of coverage.

The ACA eliminated most of these options. High-risk consumers could not be denied coverage or be overcharged. Further, every health plan was required to pay for a standard portfolio of services.

To offset losses, the federal government has provided supplements to cover costs on a year-to-year basis. The ACA has proven even more expensive than anticipated because the uninsured have been much sicker. The ACA had plans to offset these costs but they have had no major effect to date.

To force Congress to pass a new law to replace the ACA, President Trump has threatened to stop its federal supplements. That threat has already caused some insurance companies to leave the ACA. Congress, however, does not favor this action since it would leave millions of Americans without health insurance.

This situation has exposed the major weakness of the ACA — its financial fragility.

• The ACA required all Americans to purchase health insurance to create a new funding source. That plan failed because the law was poorly enforced. Now the ACA has no consistent source of revenue to offset costs.

• On the costs, the ACA is also vulnerable. The ACA insurance plans are managed by the private insurance industry. As long as insurance companies can rely on federal subsidies, they have little incentive to reduce costs.

• The bottom line is that the federal government must continue to subsidize the ACA.

This challenge is not new. With Medicare for the elderly, the federal government has a long experience with publicly supported health insurance. Medicare is a popular plan that is predictable, understandable, and accepted across the nation. Because it controls national pricing, Medicare has kept inflation low compared to private insurance.

“Medicare for All” was popular with some voters during the 2016 presidential campaign. Many now wonder why they cannot have the same federal insurance plan as their parents and grandparents.

That is a timely question. For most Americans, employee health insurance has become too expensive and unwieldy. Our U.S economy rewards workers who have geographic mobility and job flexibility. For such employees, finding health insurance in differing local markets can be a nightmare. A national health plan, like Medicare, solves that problem.

Companies see the rising cost of employee health insurance as a threat to the bottom line. Many businesses pass these costs to their employees through higher deductibles, co-pays, and co-insurance. That maneuver may reduce company costs, but it puts economic stress on employees and does little to curb medical inflation.

Americans are beginning to understand these issues and envision a future where the federal government ensures access to health care for everyone. During the ACA debate, voters sent several strong signals to Congress:

• Do not repeal the ACA without a replacement plan in place.

• Do not reduce current benefits.

• Do not interrupt or threaten any current insurance.

The message seems clear: most Americans want Congress to improve the ACA and move forward—not backwards. The only institution with the experience, power, and resources to lead the way is the federal government. If that happens, the country will be on the path to a “public option” like Medicare where the federal government is the insurer.

That option was proposed for the ACA in 2010 but was withdrawn due to political pressure from the insurance industry. Reviving the public option will likely provoke the same industry reaction. However, if voter support continues to grow, the public option could prevail. That will be a game-changer.

Planning for the End of Life: What Baby Charlie Can Teach Us

By Mark A. Kelley, MD |8/7/17
Founder, HealthWeb Navigator

Charlie Gard was a one-year-old boy who had a rare genetic disease leaving him blind, comatose, and unable to breathe on his own. This metabolic disorder can be fatal and has no known cure.

Charlie’s parents wanted him treated with experimental drugs in the hope that a miracle would happen. As reported in the press, the British medical and legal community considered this care futile and blocked it.

This sad story created a flurry of public discussion about ethics, end of life care, and patient and parent autonomy. Experts debated the wisdom of the parents’ decision. The discussion centered on whether the experimental therapy would help Charlie or make him suffer more.

These “end of life” issues have evolved during medicine’s successes over the last 50 years. Thanks to life-saving advances, premature infants have been saved. Organ transplants have given new life to patients with failing lungs, heart, kidneys, and livers. Many cancers are now curable.

However, there are limits to what medicine can do. Full recovery is rare among patients who have multiple-organ failure or advanced chronic disease. This raises the important issue of length of life versus quality of life.

As an intensive care physician, I have treated many patients facing this challenge. These situations are exceedingly difficult for everyone: patients, their families, and their medical teams. Emotions are magnified even more when the patient is young and/or cannot speak their wishes.

The major question for a critically ill patient is, “What happens next?” Sometimes, nature sends clear signals: the patient does not respond to maximum therapy, or there is no sign of brain activity. But more often the situation is uncertain. The patient may enter the twilight zone of the “chronically critically ill.” Such patients, who are often comatose, can be kept alive by machines that inflate the lungs, pump the heart, and dialyze the blood—all in the hope of a major recovery.

Research has shown that patients who need such advanced life support for many days have a grave prognosis. Those few who survive and leave the hospital usually die within one year and most never achieve full function. Physicians and families find it hard to know how aggressively to treat such patients without understanding their wishes.

This situation is preventable. While 90% of patients feel that they should discuss end-of-life plans with their family, only 27% actually do so. Knowing such plans in advance is invaluable for developing a treatment plan that respects the patient’s wishes. However, unless patients tell their families beforehand, how can anyone know?

Fortunately, progress is being made, thanks to public support and resources such as The Conversation Project. This advocacy program encourages everyone to “have the conversation“ with family when there is no pressure to make a hasty decision. The group’s website has helpful information and tools to guide the discussion. As some experts have written, we make plans for our estates—why not include our end-of-life wishes?

Charlie Gard’s parents were in a very difficult situation. They had to make a decision about his care and initially defied the medical/legal community by choosing aggressive therapy. Many supporters, including Pope Francis and President Trump, rallied to endorse the parents’ position.

That was before the medical facts became clear. According to published reports, experts agreed that Charlie’s disease had permanently damaged his brain and that he would never awaken or breathe on his own. The experimental therapy would not reverse his current state of suffering but could possibly make it worse.

Once they understood these facts, Mr. and Mrs. Gard chose to remove their young son from life support, and he died peacefully. We can sympathize with their painful and loving effort.

The Gard story has a message for us all. As a comatose child, Charlie could not speak about end-of-life decisions—but, as adults, we can. It is important to remember that the end of life is inevitable and that we will all experience it some day.

Having “the conversation” can relieve our loved ones from a responsibility that rightfully belongs to us. It may be the most important gift we can give them.

What Are the Health Risks of Exercising Outside in Winter?

By Nathan Blake |1/4/17
Updated | 10/27/17

Who doesn’t love this time of year? Leaves are changing color, the breeze smells like campfire, and pretty much everything comes in “pumpkin spice” (chicken sausage, anyone?). In just a few months, you’ll be making yet another list of New Year’s resolutions.

Last year, 41% of Americans said they wanted to “live a healthier lifestyle,” while an additional 39% wanted to “lose weight.” And let’s be honest—most of us can sympathize. 40% of U.S. adults are considered obese, a record high.

But gym memberships aren’t getting any cheaper. Rising costs have inspired health buffs to develop fitness routines requiring little or no cost such as bodyweight exercises, yoga, and dancing, or incorporate old standbys like running and cycling.

What most people don’t realize is that the physical cost of cold-weather exercise can mean devastating heart and lung damage. In fact, numerous studies show that heart attack rates tend to spike in colder months, especially December and January.

Those of you who choose to brave the cold this fall and winter should be aware of the potential benefits—and dangers—that lie ahead.

Benefits of Cold Weather Exercise

It’s a myth (more like a half-truth) that chilly weather means greater weight loss. Unless you’re noticeably shivering and expending more energy than usual, your winter workout won’t burn more calories than usual.

That’s not to say athletes should hibernate until spring.

Want to improve your mood? Exercise helps combat the symptoms of seasonal affective disorder, a form of depression affecting 20% of Americans. Additionally, more sunlight exposure increases endorphin levels, putting the “sunny” in “sunny disposition.”

Some research even suggests that 45 minutes of running in cold weather can reduce flu-risk during the winter months by as much as 20-30%.

You may be able to up the intensity of your workouts in the cold, too, since hot weather has been shown to negatively impact physical performance. Factor in the lack of humidity and the invigorating wind chill, and all of a sudden colder climes don’t seem so bad for training.

But as with life in general, moderation is key.

Now for the Dangers (and How to Prevent Them)

Don’t fall into the trap of thinking you’re capable of doing the same activities in winter as you could in summer without a hitch. If you’re in excellent health, you probably won’t experience any major issues exercising outside this winter—barring accidents, of course.

However, if you have a history of heart, lung, or circulation issues, you’re putting yourself at risk for increased discomfort, injury, and even death.

Here’s what you need to be on the lookout for if you want to stay well and fit this winter.

Muscle TearsWhen temperatures drop, our bodies overcompensate to perform tasks that would be easier in milder weather. Our muscles and tendons lose more heat, which causes them to tighten up and become less flexible. This leads to muscle soreness or damage like strains and tears.

What You Can DoTake time to warm-up properly before exercising, but save the stretches for your post-routine cool-down. Ease into your workout with some light cardio instead. Brisk walking, for instance, is great for raising your core temperature and increasing blood and oxygen circulation. Common problem areas include your hamstrings, chest, shoulders, and quadriceps. Show them some extra love!

Asthma: Ever hear of exercise-induced asthma? Coughing, wheezing, chest-tightness, shortness of breath, excessive fatigue. Winter athletes frequently report these symptoms even though they may never experience them in other seasons. Cold, dry air and exercise both aggravate asthma individually. Combined, they’re downright dangerous.

What You Can Do: Cover your mouth with a mask or scarf to warm the air you breathe. If you use an inhaler, use it 15-30 minutes before exercise to open your airways, and carry it on your person at all times. You can also drink extra water, which thins the mucus in your lungs and helps your body move more efficiently.

Heart Attack: Cold temperatures can cause vasoconstriction, or narrowing of your blood vessels. As these passageways constrict, blood pressure rises, which reduces oxygen supply and blood flow to your heart. The result is your heart works harder than it would under normal circumstances. People with heart conditions are inviting additional cardiovascular strain that may result in angina or, potentially, a full blown heart attack.

What You Can DoPeople with a history of high blood pressure and/or heart disease should consult a doctor before starting a new exercise routine. Begin physical activity slowly, and give your body a break every 15-20 minutes. If you begin to feel chest pain, or pain that radiates down your left arm, call 911 immediately or visit the nearest emergency room.

Frostbite: Frostbite occurs when the body’s skin and underlying tissues begin to freeze. As blood flow slows, ice crystals form inside your cells, killing them in the process. People with frostbite will immediately notice numbness and skin discoloration in localized area(s). Left untreated, the resulting skin tissue death can result in gangrene and amputation.

What You Can Do: Limit your exposure to cold, windy, wet weather. Keep an eye out for signs of frostbite like red or pale prickling skin, and stay dry (wet clothes increase heat loss). Dress in layers; aim for clothing that is comfortable, loose, and light; and make sure your outer layer is both windproof and waterproof. If you do notice signs of frostbite, don’t rub or aggravate the frostbitten area. Instead, find shelter as soon as possible, and treat the affected area using either warm—not hot—water or body heat.

Hypothermia: Prolonged exposure to cold weather causes the body to lose heat through the skin and lungs faster than it can be produced. A dramatic drop in body temperature (generally recognized when core temperature falls below 95 degrees Fahrenheit) slows brain function, heart rate, and breathing. Soon, confusion, fatigue, and organ failure set in.

What You Can Do: Layer up, and wear a hat, scarf, and mittens to conserve body heat. Stay dry, being especially mindful of your feet and hands. Avoid alcohol and caffeine, both of which stimulate heat loss. Seek medical attention immediately if you notice any symptoms of hypothermia. In the meantime, remove any wet clothing and wrap yourself warmly in a blanket or other covering. However, do not immerse yourself in hot water. This can lead to shock.

Even though the above scenarios may sound dire, it never hurts to be prepared when it comes to your health. Stay warm this winter, but enjoy the chill. Your body will thank you come spring.

What Do You Know About Diabetes?

By Nathan Blake |11/9/16

November is designated National Diabetes Awareness Month.

In 2012, over 9% of the American population—roughly 29 million people—had some form of diabetes. Worse, one in four people with diabetes do not know they have the disease. With over 1.5 million new cases of diabetes being diagnosed every year, this disease is quickly becoming one of the nation’s fastest growing and most serious epidemics. In fact, diabetes was the seventh leading cause of death among Americans in 2010. That number, if current trends continue, is sure to rise.

What is Diabetes?

Diabetes is a group of health conditions that makes it difficult for the human body to properly control the level of sugar in the blood. When we eat, our bodies convert food into sugars, one of which is called glucose, which our cells rely on as a main source of energy to carry out the basic bodily functions of our muscles, brain, heart, liver, and more.

Because of the importance of glucose in everyday health, there are very intricate biological processes at play to regulate glucose in the blood. These processes ensure that our glucose level does not rise above or fall below a healthy range.

The Importance of Insulin

The cells in our body cannot use glucose directly and must rely on a hormone called insulin. After eating, insulin is released into the bloodstream by the pancreas. Insulin attaches to cells and prompts them to absorb glucose from the bloodstream. The cells then turn the glucose into energy.

When there is an overabundance of sugar in the blood—for instance, after a big meal—insulin stores this excess glucose in the liver to be used later when blood sugar levels drop, such as during the period between meals or while exercising. Normally, glucose is kept under tight control by the pancreas which uses insulin to regulate the blood levels. Diabetes occurs when this regulation system fails to control the levels of glucose.

Types of Diabetes

Type 1 diabetes (formerly called “juvenile-onset diabetes”) occurs when the body cannot create its own insulin. This is because the body’s immune system has destroyed the insulin–producing “beta cells” in the pancreas. Without insulin, glucose cannot enter cells. The cells must then use other inefficient sources of energy while glucose levels rise. This metabolic imbalance can be life–threatening. To prevent this problem, patients with Type 1 diabetes must receive insulin injections daily in order to regulate their blood sugar levels.

Type 2 diabetes (formerly called “adult-onset diabetes”) occurs when the body continues to create insulin but the cells have a sluggish response to its effects. The result of this “insulin resistance” is elevated levels of glucose in the bloodstream. Over time, the high glucose level can also affect the pancreas and reduce its production of insulin.

Gestational diabetes, occurring in roughly 4% of pregnancies, results from hormonal changes during pregnancy that inhibit insulin’s ability to regulate glucose levels.

Risk Factors

While the risk factors for developing type 1 diabetes are still being studied, research shows that having a family member with diabetes can increase your risk for developing the disease. Type 1 diabetes occurs most commonly in children and young adults, accounting for roughly 5% of all people diagnosed with diabetes.

More is known about what causes type 2 diabetes, as it is the disease’s most common form. Several risk factors include a family history of diabetes, being overweight, not getting enough regular physical activity, an unhealthy diet, high blood pressure, and increasing age.

Pregnant women at risk for developing gestational diabetes include those over the age of 25, people with a family history of diabetes, and women who are overweight. For reasons that are not fully understood, gestational diabetes occurs more frequently among black, Hispanic, Asian, and Native American populations.

Treatment

Many diabetics require treatment with insulin or other medications that help control glucose. Equally important are lifestyle habits that can be helpful in preventing diabetic complications. Diabetes can be managed by taking the following precautions:

• Eat meals balanced in starches, fruits and vegetables, proteins, and fats.

• Make physical activity a daily routine.

• Monitor blood sugar levels to be sure they are under control.

• Manage blood cholesterol and lipid levels by eating healthy and taking prescribed medications as recommended by a healthcare provider.

• Control blood pressure to a healthy range (below 130/80).

Prevention

Type 1 diabetes cannot be prevented, although many studies have shown that patients can take a few simple steps to drastically reduce their risk for developing type 2 diabetes.

The Diabetes Prevention Program was a federally-funded project that monitored over 3,000 individuals who were at risk for type 2 diabetes. Researchers discovered that adults at risk for the disease were able to reduce their susceptibility by half by following two practices: healthy eating and regular exercise.

Adhering to a low-calorie, low-fat diet and getting at least 30 minutes of physical activity for five days a week were shown to be effective markers for lowering the risk for diabetes.

To learn more about diabetes diagnosis, treatment, and prevention, visit the National Institute of Diabetes and Digestive and Kidney Diseases, supported in part by the National Institutes of Health.

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