So by now all of your know that the Republican Tax bill passed. Most of you also know the tax bill is not just about taxes. With it’s passage, the Individual Mandate of Obamacare has been repealed. Therefore it is now no longer incumbent upon people to hold any health insurance. So, like an uninsured driver in a bad accident, someone else will foot the big bill when fit hits the shan.
Those of us in medicine realize that in the short term this will save the Fed money. However in the medium and longer term, it will cost far more than was saved in both monetary, productivity and human terms. I only hope that this resultant data will be kept properly so that can see the true results of our lawmaking and course corrections in policy can be made accordingly. I am beginning to consider all such bills on taxes and health insurance as politically charged estimates, and how costs and benefits actually turn out are another matter. How costs and benefits are actually tallied and reported are yet a third concern, and I daresay I will view all reports with skepticism unless their methods are sources are clearly declared. Transparency in reckoning will be critical, and in this climate of alternative facts, something fundamental will have to change.
The Congressional Budget Office estimates that premiums will go up about 10% for all policies through Obamacare simply because of the loss of the Individual Mandate. The CBO also estimates about 4 million people will either lose or forgo health insurance because of the change.
The current administration is also trying to roll back in the Contraceptive Mandate. This is the part of Obamacare which requires all health insurance to provide coverage for birth control without copay. The Democratic States Attorneys General have banded together to prevent this from happening. Their argument is that the planned rollback of the Contraceptive Mandate "for employers to include birth control in their health insurance plans is an unconstitutional endorsement of religion” and "violates the constitutional separation of church and state and encourages illegal discrimination against women.”
In science there is a phenomenon called a natural experiment. This occurs when happenstance set up a comparison between one set of circumstance and another, allowing a later comparison. For example, there have been instances of twins separated at birth and raised under different conditions. The resulting differences can then be studied.
What if there were a modern country where birth control was not readily available ? What might that be like ? While considering that Venezuela and the United States are very different, one can still view the situation in Venezuela a cautionary tale. Venezuela is experiencing a shortage of birth control. Women are using the “ counting method” otherwise known as rhythm, and using unproven folk remedies. Venezuelan health officials are noting spikes in unplanned pregnancies, sexually transmitted diseases, and unsafe abortions. Data in the United States while the contraceptive mandate was in place show abortion has hit an all time low.
In the nobody-saw-this-coming department, Ob/Gyn residency training programs in Wisconsin and perhaps across the nation might be at risk of de-accreditation. At present, the Accreditation Council for Graduate Medical Education requires that abortion training be part of residency in Obstetrics and Gynecology. Two Wisconsin state representatives have introduced legislation that would eliminate resident’s ability to complete this training, thereby putting the program out of compliance with the accrediting body. As it is, a national shortage of Obstetricians and Gynecologists is looming; it is already the case in rural areas, and will be so everywhere if trends continue.
CMS, the Center for Medicaid Services is floating a proposal to allow individual States to determine what constitutes “ essential benefits”. These are things which insurers MUST cover. As of right now, under Obamacare, things like annual exams, cancer screening, like paps mammograms and colonoscopies, and prenatal care are covered. Medically necessary surgery is covered. Emergency room visits are covered. However, with this proposal, this might change, and it might vary widely between individual states. Health care providers are worried this will leave many necessities uncovered, and insurers are worried States will want to keep insurers providing benefits, which will cost them more money.
The deadline to sign up for the ACA is December 15th. As of last week, about a million more people are signed up than at this time last year. That's what I call an endorsement.
On to the Medical News.
A new study has shown us something we have always suspected. We have known for some time that obesity is a risk factor for uterine, or more specifically endometrial cancer. (Endometrium is the lining of the uterus. ) The reality is even more stark. It turns out that fat cells drive the growth of endometrial cancer cells. In particular, a protein produced by fat cells “tells” endometrial cels to proliferate. It’s one more powerful reason to make sure your weight is optimized
In the we-already-knew-this department, robotic assisted laparoscopic hysterectomy is looking good. In particular, a recently published study compared robot hysterectomies with “open” hysterectomies, meaning the ones using a large incision similar to the incision used for Cesarean Sections. Guess what ? The robot cases with the tiny incisions, precise instrumentation and excellent visualization had better results than the open cases with large incisions, manual instrumentation, and variable visualization. In particular, this study shows they had fewer complications across the board and shorter hospital stays compared to the open cases. I should add that literature and the prevailing experience is that patients having robot cases also have less post op pain.
Stay tuned for more gripping news from the world of Obstetrics and Gynecology, here, next week, on Medical Monday.