Passenger Protection and Affordable Car Act

Let’s look at a fictitious car comparison to better understand health reform that has been in the news lately. The column below, a satire, aims to show how the health insurance industry could be jeopardized if the individual mandate is thrown out by the Supreme Court.

(Note: Medical care for the sick and wounded is very different and we should always provide for those who cannot provide for themselves.)





We have troubles, right here in River City: cars are wrecked daily and 14 percent of people do not have collision insurance. If we mandate that everyone must have this insurance, then our problem is solved. But some people have a car that was wrecked before they took out insurance and need help getting insurance. OK, we will mandate that every insurance company must accept even cars that are known to need repairs.

Let’s say insurance costs $500 per year but the penalty for not having the mandated policy is $100 per year. Why pay for insurance if you are given the right to be accepted for insurance, when and if you ever need car repairs? Insurance companies will have fewer customers and more payouts for repair. They raise rates and find that even more people get off of it. Even those who buy the high-priced insurance when they have a wreck just cancel the policy after repairs. New standards for a policy state that you cannot get a high deductible and it must include check-ups, including oil changes.

How is this fictitious Car Act similar to the Patient Protection and Affordable Care Act ( ACA or commonly called Obamacare) ?

· no one is denied insurance based on pre-existing conditions.

· penalty for not taking out the mandated individual health insurance policy is only a few hundred dollars a year. Many will just pay the small penalty and take out a policy when and if it is needed.

· The penalty for an individual making $20,000 is about $500 per year; and only half of this the first years. Who can get health insurance for $40 per month?

· The penalty for a family is about $2,000 per year, so for a family of five it is $33 per person per month.

· The penalty for an employer with over 50 fulltime employees is $2,000 per year or $166 per person per month – cheaper than providing insurance for your staff.

· policies have standardized premiums and coverage, and less options for trying to save money but choosing a plan with a higher deductible that limits coverage for something like maternity. “Essentials” that must be included in a package of benefits: ambulatory and emergency services; hospitalization; maternity/pediatric; mental health/substance abuse ; prescriptions; rehab; lab; preventive services including oral and vision care.

· all preventive services are covered with no copay or deductibles

· no million-dollar limits to what insurance must cover.

· local communities will address: health disparities, reduction of chronic disease, promotion of healthy living, posting calorie counts at chain restaurants.



If the Supreme Court rules that the individual mandate is illegal, then under ACA there would be 8 to 23 million fewer people insured. Estimates for increases in premiums range from nine to 27 percent. For many who are barely able to pay for insurance, this increase will cause people to lose insurance coverage.


The theory goes like this: without a mandate, we do not get the young and healthy to pay into the insurance system. Mostly the sick sign up because they need insurance to pay for ongoing problems. Insurance premiums would rise steeply and eventually even the sick can’t afford it. The insurance industry goes into a “death spiral,” paying out for sick customers, increasing premiums and getting fewer customers to buy insurance. Eventually the insurers will bust.

What are these troubles in River City and how many will have the potential for getting insurance? This presumes that the insurance industry survives. Of the 320 million people living in the U.S., about 90 million are excluded from the mandate due to already being covered by programs like Medicare and being in poverty.

This leaves 180 million people subject to the mandate of having to get their own insurance policy. Only 14 percent of these people (18 million) do not already have insurance, presuming the insured do not drop coverage. Now, 11 million of these can get a federal subsidy to get insurance. So the mandate really only affects 7 million people in the U.S. This is 2 percent of the population.

Joel Cantor, Rutgers professor, states: “You would be irrational to buy health insurance until you are sick and the insurance industry simply can’t exist with that model.”


John Sheils of the Lewin Group: “The problem with eliminating the mandate is that it will create a situation in which people aren’t taking much of a risk by going without health insurance.”

Or let’s leave it on a more cheery note (if you see this as cheery and realistic): Susan Dentzer, an analyst for the PBS NewsHour: “ … is the individual mandate really the “linchpin” ?.. Probably not … [but] …Clearly, the market – and many millions of people – would be worse off … it’s not at all clear that the Affordable Care Act could be amended … But with two-thirds of Americans opposed to the mandate … it’s a good time to start talking about alternatives.”

CIMT- Ultrasound Test for Fatty Plaque

CIMT- Ultrasound Test for Fatty Plaque



If you could do a simple 10-minute test in a doctor’s office to find out if your arteries are getting clogged, would you do it? There’s an ultrasound of the neck that shows early stage thickening and plaque of the carotid artery: Cimt - Carotid Intima Media Thickness.

If you knew that the No. 1 killer we face is clogged arteries, would you want to prevent it, monitor it and clean it off? Even a little fatty plaque could break off and cause a clot like a heart attack or stroke. Sudden death is the first symptom in 50 percent of cardio-vascular disease.



If you knew that 80 percent of heart attacks are preventable, would you make sure that you’re not at risk? Risk factors that we know about in 2012 go beyond the traditional factors (see footnote).

So let’s look at two people and how they approached this risk:

JD and JQP are 45-year-old men who have the same amount of artery wall thickness and very early stages of atherosclerosis “fatty” plaque.



JD thinks that he is OK since he has not had any of the traditional cardiovascular risk factors. He considers himself rather knowledgeable about health issues like which type is the good cholesterol, etc. He admits that at 45 he should get a check-up. He has noticed a few extra pounds on the belly and is surprised that his bmi (body mass index) is 28; not quite obesity of 30 but not ideal like 25.

His blood pressure and cholesterol are borderline high. He reluctantly follows the doctor’s advice, gets a CIMT but does not follow-up. He is determined to get healthier and in fact lowers his weight and blood pressure. He didn’t want to take any pills and figures that in two years his CIMT would show that he has cleaned off his arteries. He would have been correct because lifestyle changes sometimes clean off arteries.

JQP doesn’t know much about “cholesterol stuff”. At 45 he feels fine but realizes that he could have done a better job living healthier. He smoked for several years in the past, he’s had a little beer belly since his 30s and he’s loves beef and rich food. He gets a CIMT and takes what the doctor advised: a single combination pill that lowers blood pressure and cholesterol and an aspirin. He makes some lifestyle changes at first like some walking exercise and watching his food intake, but human nature takes over and he’s back to his old ways.

JQP who took the pill, showed improvement on his CIMT test the following year. The doctor explained how not only has the plaque lessened, but it has a more stable edge that is less likely to break off to clot. The low-strength aspirin helped keep down clotting also. He still looks a bit unfit but the doctor knows that his arteries are looking more fit. He still encourages diet and exercise, otherwise diabetes might develop and more pills will be necessary to try to counter a continued unhealthy lifestyle.


JD did not do so well. He had a good idea to get even more fit but he was unlucky. He started a strenuous exercise plan without getting cleared by a treadmill stress test. He did not want to take the aspirin a day. He declined the prescription for a statin for his cholesterol. Even though he only had a small amount of plaque in the lining of his arteries, it was the unstable type. One day it broke off causing clots that traveled to his heart and brain. He had always said “ya gotta die sometime” and the clot causing the heart attack would have caused sudden death if it had set off fibrillation. Instead a third of the heart muscle was damaged from loss of blood supply and now he has heart failure. Another clot caused the stroke and he is paralyzed on one side.

The above stories are happening daily but there is no specific or actual cases of JD (John Doe) or JQP(John Q. Public).

The take-home message remains the same: get a regular physical and ask about available screening blood tests. Ask about the risks of testing and of taking medicines. If you decline testing or treatment, be sure to understand options and get specialists’ opinions.



Note: Visit my website: PvilleHealth.blogspot.com to see discussions of traditional and emerging risk factors: Traditional: cholesterol, blood pressure, obesity, smoking, genetics, diabetes. Emerging: subtypes of cholesterol (LDL, small LDL, Lpa, HDL, HDL2, non-hdl, TG, apo A and B) , CRP-hs & LPpla2, apoE, HbA1c and glycomark, etc.

Vasolabs.com has information about their ultrasound techs who can come to doctors’ offices to do CIMT sonograms.

Also a future article on CIMT will be written if there is interest. If you want to leave any comments or questions, just type it in the comment space. It will not be published unless the writer requests it be. The comment space on this site was set up so that people do not need to leave any name or email. No individual medical advice will be given but future articles and blog entries will address these comments.

Living the Life of Hospice

In this time of year where there is such celebration of birth, it may seem strange to talk about the other end of the spectrum, the process of dying. But in the big circle of life, both can be celebrated as part of the life process. In facing our inevitable end, there is dignity. Unlike modern western societies, most people historically and in the world even today spend their last bit of time at home. Hospice allows a dignified good dying experience at home or wherever the person resides. Facing death with the help of hospice nurses and staff can prepare family members also. Often misguided guilt from the patient or family is dealt with and grieving is helped.

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Ask someone about “hospice” and you’ll get lots of misinformation:

“ Isn't it a place that they put you in when you’re about to die?”

Really, it’s a team of supporting healthcare providers who will be there for you and your family, anywhere including your home for the last six months of life.

“Won't they stop treating you and you die too early and in a bad way?”

Actually you will receive any medical treatment that helps your symptoms and improves the quality of life. For example radiation treatment that shrinks a cancer mass causing symptoms will be performed. But if a long course of radiation or chemo is desired in a late stage cancer for a low likelihood of possibly prolonging life a few months, then it is not covered by hospice. (Remember that many people suffer a low quality of life and premature death with such treatment at this stage)

“Once you sign up then you can’t get off.”

Not true. You can get off of hospice at any time. But often patients and families are so pleased with the supportive care and having all of the meds and supplies being provided, that they don’t want to get off.

“It must cost a lot for health and supportive care like that.”

Medicare and other government and private insurances cover hospice, which pays for just about everything.
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When a person is starting the dying process, they or their family believe they “lost a battle” when it is really a no-fault situation. Besides early stage cancer, there is often a myth of curative treatment for many severe, chronic conditions that are in a late stage, according to Leigh Fredholm, M.D. of Austin Hospice. She and other speakers are available to discuss hospice and even show the 30-minute documentary “Except for Six”, taking the journey of Ron, his family and the staff through his hospice experience. Hospice has experience dealing with families especially when they get to know them over months. This is better than waiting to the very end.

. . . Now I lay me down to sleep…

There are good things about knowing that death is coming. You can prepare and have all your stuff arranged for. Family and friends have the opportunity to visit more. A good reference is the 1969 pivotal book, “On Death and Dying” by Elisabeth Kubler-Ross. This book (online atEKRfoundation.org) deals with death and dying including denial, which is better discussed before the very end.

Maybe we can make the analogy of the midwife and the hospice nurse: birth being like an awakening and death like sleep; both can be a tranquil and beautiful experience.

. . .Silent night, Holy night…


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HospiceAustin.org

- Hospice Austin is a not-for-profit hospice for over 30years. It has the goal: “emphasis is on living each day to the fullest, in a comfortable place, free of pain and in the company of loved ones. “

-Hospice Austin's Christopher House is located at 2820 E. Martin Luther King Blvd

-Anyone can call 800-445-3261 for hospice information, at any stage of serious illness

- The team usually consists of a physician, nurse, social worker, home health aide, homemaker, volunteer, chaplain and bereavement counselor (as requested) — all working together and focusing on the needs and wishes of the patient and loved ones.

PeacefulTranquilityHospice.com

– a personal thank-you from me. They provided wonderful care for my mother at her home in Galveston

Local cardiologist has new website- NutritionHeart.com

Dr. Roehm’s practical nutrition advice on the internet is very different from a flippant cardiologist speaker I once heard. That speaker was asked about whether to start with diet before pills; he remarked: “I personally start by writing a prescription that costs a lot. When they return, they seem very interested in my discussion about behavior changes that they could make to eventually get off those expensive meds!” Let’s have that discussion now. Better yet, stop reading this article and type in NutritionHeart.com; then sit back and watch some entertaining videos that will teach you some things.

You will learn about diets that have proven to lower heart attacks and overall death rates. In the process you will find out about different type of studies. So the next time your buddy reads some headline in an ad or even in the news like: “95% of people who take vitamins are healthy”, you will know what to ask. Was that an observational study? (duh, people who already are health conscious are more likely to turn to vitamins, and anyway, the majority of people are “healthy” by many definitions). Or you might ask if two groups of similar people were randomized to take vitamins or not.


There is actually a study where they randomized similar groups of people to either go on a diet very similar to that of Crete or no change in diet. This Lyon Diet Heart Study had amazing end results: not only was there a decrease in further heart attacks by 70%, there was a decrease in overall death by 60%! This is more scientific proof of benefit than has ever been shown by low fat diets, South Beach diet and even the DASH diet.
On this web site you will get Dr. Roehm’s practical advice as an experienced cardiologist, who practiced in Round Rock. He says that what is important to watch in a study are end results. We care more about how to be a person without a heart attack, even though his numbers like cholesterol might be higher than a person who died from a heart attack with “great numbers”. (In this study both groups had similar LDL & HDL cholesterol as well as blood pressure .


So what is this special type of Mediterranean diet? It’s not vegetarian but your vegetarian friends might like seeing that it has low amounts of animal products. Besides lots of fruits and veggies, they like their beans,peas, nuts, whole grains and yogurt. They get plenty of protein without eating much meat although they do eat chicken and fish. Avoiding fatty meats keeps down the harmful saturated fats. But don’t think you have to stop all the fat because you can use good olive oil and canola oil. Instead of white bread and desserts, they enjoy cheese and a 5 ounce glass of red wine a day. But as Dr.Roehm explains in his video, any change in alcohol intake or diet changes should be discussed with your health care provider


So what’s the best answer: diet and behavior changes or prescription meds? The answer is often both.You will hear how Dr.Roehm dealt with many people with hypertension over the years whose BP could not be controlled even with multiple pills. Individually he worked with his patients to taper off sodium/salt and change some lifestyle behaviors. Many were able to be taken off some of their meds. Now he offers this web site for all who want to learn some things about nutrition and the heart.


Have you heard how to stop high blood pressure with a change in your diet, where you don’t have to lose weight? National Institutes of Health studied the Dietary Approaches to Stop Hypertension (D.A.S.H). With this diet and lowering your salt in your food, you can lower your BP as much as a mild blood pressure pill.
Who hasn’t heard of the benefits of fish oil? But how does it work and how much do you need? Short answer – check the label for a total of 1000 mg of omega-3 from fish. Long answer- NutritionHeart.com. But you’ll learn some things about mercury in the oceans and even about reducing joint inflammation and fish oils.

There are quick links to his videos, handouts, transcripts, scientific background and web links for Low Sodium Diet, Mediterranean Diet, DASH Diet and Fish Omega-3 Fat. Also listed are topics on how the Mediterranean diet relates to Alzheimer, diabetes & cancer. Be sure to read about alcohol and heart disease, alcohol and women’s health and future topics on exercise.
NutritionHeart.com not only has the video talks from a cardiologist, it allows for printable handouts, transcripts and summaries. It is a nice web site with no ads, no registering, just down-home health information for you and your loved ones.