Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Policy news this week centered on reaction to the government handling of the proposals for healthcare perform. As before, observers from all sides have noted that proposed changes would result in over 20 million people becoming uninsured, adding to the financial and human burden that we would face. It would also result in premium increases of approximately 20% across the board according to the Congressional Budget Office, and this, well before the next election.

In a stunning turnaround Senate Majority Leader Mitch McConnell (R-Kentucky) warned that if the GOP senators could not get 50 votes required to repay and replace the ACA (Affordable care act), then, (emphasis mine) THEY MAY HAVE TO WORK WITH DEMOCRATS to repair the existing marketplace. The current proposal will, in fact fail since only three Republican votes against it could sink it, and there are many more Republicans than that opposed to the bill.

Delaying action on the GOP plan for healthcare until after July 4 recess week had one interesting unintended consequence. Congressmen returned home for about nine days, not just 4. In that timeframe they had plenty of time to hear from the local officials at home most pointedly, from the Governors of their respective States. Governors are worried about losing billions of dollars in Medicaid funding if the Affordable Care Act repeal bill is passed. Washington will not inherit all the problems that ensue if the ACA is repealed, they will.

Plans under consideration and go all the way from the Sanders bill introduced by Democrat Bernie Sanders which provides for "Healthcare for all", to a buffet style set of plans favored by senate Republicans from Texas and Utah, where one could buy plans in conformance with the Affordable Care Act or less costly, less comprehensive plans geared for healthier people. The problem of course with this is that it short-circuits the whole beauty of broad-based health insurance which pools risk and pools money. Money for low risk people subsidizes the poor and those who are misfortunate enough to sustain expensive and long-lasting illness. It is this exact feature to which many people object, not feeling an obligation to those less fortunate than themselves. I feel people of this opinion exhibit not only a lack of compassion but a lack of fiscal common sense. Money spent on the health of the poor, on early diagnosis, on pregnant women, and money spent keeping up on the care of the chronically ill is money saved and an insurance policy for a better future.

In the Texas and Utah plans there would be a multitiered system of healthcare where some people would not get all benefits. Physicians like me know that one's health cannot always be predicted and that the unexpected does happen. Thus, patients given the option of incomplete plans may find themselves wanting for adequate coverage. Physicians like me also cringe at the notion of a double standard in in health care since it is our training and our philosophy to believe that everyone should get the best of care all the time.

At the present time, under the Affordable Care act, IRS (The Internal Revenue Service) has a role in enforcing the individual mandate. The individual mandate is the portion of the Affordable Care Act which requires that individuals must maintain health insurance at all times or be fined. GOP lawmakers are currently working on a plan to prevent the IRS from enforcing the Affordable Care Act individual mandate. I think you would be hard pressed to find a physician who does not support the individual mandate. 

In our country, one must have auto insurance in order to exercise the privilege of operating an automobile on public roads. Conventional wisdom and existing data teach us that if one does not maintain auto insurance that one poses a significant liability to others. In my opinion, not having individual health insurance is exactly the same thing. Without insurance, one is less likely to obtain contraception, less likely to obtain vaccinations, less likely to obtain mental health and substance abuse treatment, and more likely to blow into the emergency room with some health crisis or accident costing the healthcare system and taxpayers a huge amount of money.

In medical news, the number of total births has declined for two years running. Most notably the teem birthrate has decreased to nearly 10%. Unfortunately rates of preterm birth continue to rise.

In the absurd department, both the UK and United States noted increasing rates of labioplasties not only among women but particularly among teenagers. A labioplasty is the surgical modification of the labia, the flaps covering the vagina, often for cosmetic purposes. Obstetricians and Gynecologists in both British and American Societies of Obstetricians and Gynecologists as well as Pediatricians have sounded the alarm over this trend indicating that it may be a sign of a deeper disorder called body dysmorphic disorder. They have called for clinicians to screen these patients accordingly. I also have to observe that this trend highlights the power of media images in our lives, including those provided by what must be classified as porn.

A recent study of robust design has revealed that women consuming large amounts of sugary foods and drinks in the latter part of pregnancy produces children who are at higher risk for allergies and asthma. The study was published in the European Respiratory Journal. It been hailed as a strong study with a large number of participants. A call has been made for additional research to understand exactly how this works.

In the we-already-knew-this department, a recent study has confirmed that women’s cognitive performance is not affected by her menstrual period. This was documented recently from a study published on July 4 in the journal Frontiers in Behavioral Neuroscience.

In the concerning department, new research has shown that poor sleep may be associated with an increased risk for Alzheimer's disease. It is not at all clear whether the poor sleep leads to the Alzheimer's or whether the impending Alzheimer's leads to the poor sleep.The study involved sampling the spinal fluid of cognitively normal people with an average age of 63. Specific physical findings are present in the spinal fluid which can be followed to determine this relationship. This is clearly an area deserving of more research and this is a step in the right direction. The findings were published online July 5 in the journal Neurology.

In the good news department, a new study has shown that simple aspirin may reduce the risk of complications for those pregnant women who have antiphospholipid antibody syndrome. Yet another study has shown that a simple dose of aspirin at 150 mg per day significantly reduced the incidence of preterm preeclampsia (toxemia) in high-risk women. 

Also in the good news department, clinical trials for Zika virus vaccine are underway. Zika virus can potentially affect all people who contract it,. Most distressingly, it produces serious birth defects in the fetal brain if the Zika virus infection is contracted by pregnant women during her pregnancy. A working group consisting of bioethicists, OB/GYN's, vaccinologists and others have recently released a set of ethical guidelines whereby pregnant women can be included in these clinical trials.

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, right here, next week, on Medical Monday. And remember... it really matters when you contact your elected officials to tell them what you think. 

Medical Monday: Breaking news from the World of Obstetrics and Gynecology

Health and Political concerns for women have merged into one. Many of you have appreciated this for some time, but now the topic is mainstream. 

Last Wednesday leaders representing over half a million medical students and doctors gathered to lobby Senators against the so-called BCRA (Better Care Reconciliation Act).Among the leaders were the Presidents of The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists (ACOG). They validated and reiterated widespread concerns that without the ACA (Affordable Care Act) or similar, people will delay or forgo care. For example, under the new proposal, older patients will have cost sharing reductions curtailed in 2 year. The leaders also voiced concern about allowing individual States to determine what constitutes essential benefits. Dr. Munger of the American Academy of Family Physicians indicated this compromising essential benefits would constitute a special threat to people with chronic, rather than acute conditions, since their essential health needs are ongoing. The President of the American Academy of Pediatrics indicated that there will be a calculable “ body count” associated with this proposed law. 

Dr. Haywood Brown, President of ACOG, stated the legislation represented an “ assault on women’s health”. He elaborated, saying BCRA could result in women and men paying differently for health care. It would end the guarantees on preventive care, i.e screening tests like paps and mammograms. Dr. Haywood also noted that fully 50% of pregnancies are unplanned. The BCRA bill would end guaranteed coverage of contraception and maternity services. These changes would worsen the already terrible trends in maternal mortality in the United states. He states he feared going back to the time when having a baby could lead to bankruptcy, and when treatments for cancer were not always within reach. Indeed, the Journal Cancer has published a study containing projections of the numbers of increased cases of late-stage breast cancer that will be diagnosed during to loss of access to screening mammograms. As if to drive home the point ,the Journal Cancer Epidemiology contains new research indicating that breast cancers appear to have been diagnosed earlier after the ACA was implemented. 

California has its own contraceptive requirement, a goal that many States are now have accomplished or are working toward. The California policy, in place since the first of the year, requires that insurers cover contraception. It also requires that they cover 12 months of it at a time. It is estimated that in California, it will reduce the number of unintended pregnancies by 15,000, the number of miscarriages by 2000, and the number of abortions by 7000. Health care costs will be reduced by 43 million dollars annually. 

Low income women are at particular risk if the BRCA goes through, since it would phase out the Medicaid expansion in a more permanent way than the ACA would. Of note, half of all births in the US are covered by Medicaid. One fifth of all American women use Medicaid. 

Many observers have noted that BCRA healthcare bill disproportionately affects women, since it targets maternity, screening, and contraception. Bill Cassidy (R-LA) has come forward to say that the law should include provisions for all insurance plans to include prenatal care and for laws that require employers to grant maternity leave for both parents. Hooray for Republicans standing up for women’s health ! I did a little research and found that Senator Cassidy and his wife are physicians who feel this aligns with their Christian values. Why is this so rare ? 

Another group is at risk of losing affordable insurance: Those who obtain their health insurance through their work. The Affordable Care Act currently mandates that businesses of a certain size offer their employees health insurance. That requirement is due to go, all or in part, by the wayside. 

Modifications to the BCRA plan are under consideration. GOP senators had considered scrapping the “ wealth tax” on those families making more than $275,000, but now they are considering keeping it to help pay for extra funds to combat the opioid epidemic. Furthermore, GOP senators have conceded, at the urging of insurance officials, that the individual mandate be kept indirectly in that a penalty fee will be levied against all those who do not maintain health insurance at all times. Insurance industry representatives have asked for this to help stabilize the insurance market. Personally, I think it is an important part of any health care plan, since it requires people to prioritize their health, it enables people to comPlanned Parenthoode in for care especially screenings, and it protects patients, caregivers, hospitals and the rest of us paying insurance against direct or indirect financial loss due to health mishaps. 

Two GOP Senators, both women, have criticized the BCRA over its defunding of Planned Parenthood. 

Personally I think it would be just fine if the GOP scraps the ACA then puts it all back together piece by piece, gives it a different name, and takes full credit for it. I just hope that, being Republicans, they find a fiscally responsible and sustainable way to fund it. I favor heavy vice taxes. Why ? Because they discourage vices ( true and documented !) and they make lots of money for the public coffers. Cigarettes are heavily taxed, but they could get taxed even more. Alcohol could be further taxed. Soda taxes could be tried but have not been popular… too bad !  Finally, in my opinion, marijuana should be taxed in those States where it is legal, for all but those with legitimate cards. FaIling these, I favor increased gas taxes and increased sale taxes on luxury items. 

On to the medical news. 

Zika precautions for pregnant and potentially pregnant women are still in place. Travelers heading anywhere south of the Mason Dixon line should inquire on the CDC.gov website about regional risk. 

Opioids. These are the pain pills or IV drugs, the morphine derived compounds that are so addictive. It turns out they are not really that much help with actual pain. It turns out they work less and less well over time, and that eventually, they need to be taken just to feel “ok”.  Patients often begin them for legitimate reasons, but then end up taking them just to cope. They may not even realize they are addicted. Doctors give them for legitimate reasons, but also because they are lazy. It is hard to say no, especially when you think that saying no will cause your patient to leave your practice and medical care altogether. A new study has found that about half of opioids are given for mental health disorders rather than pain. Physicians and patients need to be educated. It is estimated that half a million people will die in the next decade due to opioid abuse, unwitting or otherwise. 

Flu vaccine may be delivered by a painless patch in the future. A new study published in The Lancet reports on this research. I wonder if this will enhance vaccination rates. 

Increased rates of air pollution are associated with shortened life spans. A new study published in the New England Journal of Medicine indicates that “ safe” levels may be lower than previously imagined. Indeed, there may be no “safe” level at all. 

ACOG recently held its annual meeting. New research presented there focused on media representations of female genitalia. Dr. Cheryl Iglesia noted that images of female genitalia are “highly-curated, and extensively retouched” before being presented on the internet, “ leaving men and women little idea of the real range of normal efface genitalia”. She has suggested that this distortion is associated with a sharp rise in labioplasty surgery in the last year. Ten thousand such surgeries were done in the past year, a rise of 23% compared to the previous year. ACOG has issued a Committee Opinion document “...expressing concern about the lack of data and deceptive marketing practices surrounding a number of cosmetic vaginal surgeries”.

So much news ! Stay tuned here next week … for Medical Monday. 

Meanwhile contact your elected officials at Congress.gov !! It's Independence Day ! Exercise your freedom !! 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

On last Thursday afternoon June 22nd the Senate unveiled their draft of the ACHA the American Health Act, which they are calling the “Better Care Reconciliation Act". House Minority Leader Nancy Pelosi put it well: This is a “…tax bill disguised as a health care bill.” As readers begin thinking about it, they should consider that it does one main thing: it shifts the cost of health care away from the Federal Government. 

Most doctors understand that decent health is fundamental to all human happiness and prosperity. Indeed someone once said health is our only real wealth. Additionally, many social scientists and other bean counters have discovered that standards of living go up when the quality of a population's health rises. It has been conclusively demonstrated that particularly when the quality of the health and status of women rise, the entire society benefits, in both social and monetary terms. When there is good access to maternal and child health care, infant and childhood mortality decrease, maternal health increases, and family size shrinks. Earnings, savings, and educational status rise. These are well documented phenomena. 

So called Obamacare, aka the Affordable Care Act (ACA), made the health of women and children a priority. For example, the ACA included mandated insurance coverage of maternity care. Yes, this meant that the cost of giving maternity care to some was shouldered by all, since everyone contributed to a “pot” that paid out for maternity care expenses.  Implied is the notion that society as a whole has a vested interest in the welfare of pregnant women and the children that they bear. The idea is that it is our collective responsibility to ensure the well being and betterment of the next generation. 

Indeed the whole notion of insurance used to be that people could rest easy knowing that they had a way to deal with life’s unexpected or costly events. They could contribute to a pool for emergencies and other medical needs, and it would be there for them when the need arose. This was by mutual agreement between all the contributors and governed by certain pre-agree upon stipulations. Everyone knew that more people meant better benefits and more stability of the fund. 

Health insurance was viewed as a social and financial responsibility. Nonetheless, if you did not have heath insurance, you would still get emergency care, since the moral values of society and the medical profession would kick in. At the same time, people who could get health insurance but didn’t were viewed as irresponsible since they would simply take their chances or let others foot the bill if they did land up in the hospital. 

People in the US disagree about what constitutes the responsibility of government. They disagree about the role of government in health care. However, progressive and prosperous countries across the globe have examined the question from a data- based rather than political point of view. They have determined that the social and financial benefits of universal health care coverage are well worth the price. In developed countries, the government sees to the national security, and it sees to our infrastructure. These are examples of enormous and costly tasks that no one person, family, or even state could accomplish. But, a nation can. Health care is like that. A healthy prosperous nation requires massive collective input, both from a planning standpoint, and a financial standpoint. I can think of no better use for the collective monies obtained through our taxes. In this light we consider the new health bill draft. 

The new health plan draft basically proposes massive cuts in what the Fed spends on health care. Not only does the Fed currently spend on Medicaid and Medicare, under Obamacare it spends by paying private insurance companies "subsidies” so that the the insurance companies can charge more reasonable premiums to consumers. 

This great reduction in Federal expenditures toward health care would be accomplished in several ways. First it will reduce the number of enrollees.The mandate to have insurance would be eliminated. Fewer people will therefore obtain insurance. They will also curtail the number Medicaid enrollees by making requirements more stringent and by rolling back the Medicaid expansions. The assumption is that these uninsured folks will simply not cost the Fed money. However they will cost someone money over time as they end up in the Emergency Room with their unmet health care needs and emergencies. The health care system and the insured patients who pay into it will cover their bills, and health care costs will have to rise to compensate. 

Secondly, the Fed will save money by asking consumers to shoulder a higher percentage of their health insurance costs by paying higher premiums and having higher deductibles. In return the Fed plans to offer “ tax credits”. Tax credits are not money. They are a lower tax bill at the end of the year. But who can use tax credits ? Only people with appreciable taxes. Tax credits will do low income or even middle income people little to no good. These are the people who need the most help. 

Thirdly the Fed will save money by requiring States to pay more for health care. They have proposed cutting Medicaid money dispensed to states giving instead “ block grants” of lesser value. 

Fourth the Fed plans to make huge cuts to key health organizations such as the National Institute of Health and the Centers for Disease Control. 

Fifth and perhaps most importantly, the Fed will save money by cutting services. First on the chopping block is the contraceptive mandate. And if some of you say the Fed will only pay through the nose for increased unintended pregnancies, fear not, there is talking of cutting maternity services as well. Emergency services and mental health services will be cut, and Planned Parenthood is to be defunded. 

The anticipation is that millions would lose health insurance altogether. The related expectation is that costs for those that remain in the market will skyrocket. Millions of tax dollars will be saved, and this will be trumpeted as a great benefit. In fact it will be a benefit only to those with a significant tax burden. Those with bigger incomes will obviously benefit the most, since they pay the most taxes. So, in the final analysis, money for the general welfare of the nation, the care of pregnant women and children, and the care of the poor will be taken out of the public coffers and placed back in the hands of the well to do who currently pay large taxes. Make no mistake, these wealthy people will still pay high taxes. They will just be slightly less high. The degree of good done by the tax cut for the wealthy will not match the harm done to the poor by the loss of their insurance. 

This plan would most likely result in millions of uninsured. There will be less health screening. Thus there will be fewer pre-cancers and early cancers caught and treated. There will be more unintended pregnancies. There will be more abortions, and more STIs. There will be more unreimbursed emergency visits at hospitals. There will be more missed work, unemployment and disability. There will be more resentment. 

The betterment of society is a collective responsibility. There are some older senators who have complained that they do not want to foot the bill for birth control or maternity care since they themselves will never need any. How would they feel if I said I did not want my insurance premiums to encompass the burden of paying for those who smoke, drink, or do not stay fit ? Perhaps I should start an insurance pool for the young, fit and beautiful. That would be great except they would not let me in. 

A firestorm of objection has been lit. Among the incensed are Senate Democrats. Also objecting for different reasons are certain Republicans: Rand Paul (KY), Ted Cruse (TX), Ron Johnson WI) and Mike Lee (UT, and others, members of the so called “ Freedom Caucus".  Also expressing reluctance were other Republicans Toomey (PA) and Collins (ME). 

Top medical groups have criticized the bill, most notably and loudly, the American College of Obstetricians and Gynecologists (ACOG). It is worth repeating the College’s statement on the legislation: “ Despite numerous efforts to collaborate and provide input throughout this process, women’s health expertise was rejected. It is reckless for legislation that will have such an immense impact on American lives and the economy to proceed without the opportunity for public hearings or any external commentary.”. 

On Capitol Hill there were angry protesters demonstrated, many of whom were in wheelchairs. 43 were arrested. Elsewhere across the country, demonstrations have been taking place. It seems the whole country is worried and upset. 

What’s next ? The draft goes to the Congressional Budget Office. There they will attempt to assess the direct and indirect, short term and long terms costs of the proposal. From there it may make it to the Senate floor for debate. If even as few as two Republican Senators disapprove of the bill, it will not pass. 

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My father in law was a conservative gentleman who practiced Obstetrics and Gynecology for over 40 years. He was a Republican and very active in medical politics, advocating for  better health care for pregnant women across the state. He passed on a couple of years ago. I am glad he has not witnessed the degeneration of the Republican party and the disregard with which health care, women, and children are being treated. 

Medical Monday, medical portion, will have to come in a subsequent post, since this is already a very long dispatch. 

Again, please accept this reminder to call your Senator and let them know what you think. 

And for something upbeat, take a look at a book I just finished. It is called The Year of Living Danishly. You will get some smiles, but also some understanding of how another very successful country runs the relationship between taxes, health care, and happiness. 

Medical Monday: Delayed Edition

After I got my diagnostics squared away, I discovered ACOG’s ( American College of Obstetrics and Gynecology) news site was down. Members like me have access to their news and research paper aggregator. I use it as my starting point for creating your news digest blog post page Medical Monday. Finally, all is well and we have some catching up to do. 

GOP leaders have once again announced a deadline for a vote on their health care plan, the American Health Care Act (ACHA). The deadline is to be the end of June. However, as of this writing, there are still significant disagreements over the particulars. Moreover, the drafting of the bill has now gone behind closed doors. This has met with consternation not only from Democrats but from Republicans too, since such interested stake holders cannot have a say or even see what is going on. 

The Department of Health and Human Services, (HHS) has a nonpartisan economic unit called The Office of the Actuary. According to a recent analysis done by this office, adoption of the ACHA would cause out of pocket expenses to rise about 61%. This means premiums and deductibles would rise 61% for the consumer. While the real cost of the premiums would be somewhat lower, the government subsidies to defray them would diminish, leaving the consumer to pay the difference. The current administration wants to pay less, and wants we consumers to pay more. Remember that the government’s money is really our money, collected in the form of our tax dollars. While about 29% of the American public supports the ACHA, it is not formally supported by a single State government. This is because the Fed is trying to do to States what it is doing to us. It is trying to shift more of the financial cost of health care off of itself and onto the States. If the current administration succeeds in shifting health care costs to the consumer and the States, it will claim it is saving taxpayer money.

Many of you are already aware that Texas is facing a crisis in maternal morbidity and mortality. Concern is mounting that the crisis will only get worse if the ACHA is passed, since it will reduce already limited funds for the care of women and pregnant women. 

Business leaders are starting to register concern about the looming changes in health care. In particular, the cancellation of the contraceptive benefit is projected to have huge economic and social repercussions for American families, such as spikes in unplanned pregnancies, and ripple effects though the workplace. A statement by Allan Peace of Trillium Asset Management notes that “ institutional investors… see compelling evidence that widespread access to sexual and reproductive health care benefits” promotes  the “interrelated outcomes” of women having greater control over their lives and the facilitation of economic growth. I would add that this has been demonstrated not only domestically, but around the world. Yes, prosperity and the status of women are directly related. 

In the good news department, Maine is the next in a line of States taking matters into their own hands. They have passed legislation requiring insurers to pay for up to 12 months of birth control at a time, and have prohibited insurers from charging copays for birth control. They cited data from California indicating that the unintended pregnancy rate fell by 30% when they enacted similar measures. Twenty eight states now have some sort of contraceptive equity law, aiming to make contraception very affordable or free. Let’s hope we get 50. 

The Royal College of General Practitioners has presented research again confirming that oral contraceptive use does not confer increased long term cancer risk. 

In further good news, the City of San Francisco has spelled out clearer rights for breastfeeding women in the workplace. This includes the stipulation that employers provide a clean private space with electricity, a surface and a chair. 

In medical news, Zika is back. Zika is a virus carried by the Aedes Aegyptae mosquito found from the southern US southward. When contracted by pregnant women, it causes serious malformations in the nervous systems of developing babies. 1900 women in the US have had confirmed Zika infections. The proposed White House budget proposes an emergency fund for Zika but would also cut billions from budgets of the National Institute of Allergy and Infectious Disease and the CDC (Centers for Disease Control) where work is underway on a vaccine. The first cases of the 2017 Zika season have come in from … Texas. 

A new study confirms from JAMA Pediatrics indicates that even small amounts of alcohol in pregnancy may result in babies with slight facial abnormalities. 

Obesity (BMI of 30 or more) is a huge problem. However being overweight (BMI 25-29) takes its toll as well. New research published in the New England Journal of Medicine indicates that, worldwide,10% of people are overweight. Altogether 30 % of the world are affected by weight problems. The US leads the world in obesity in children and young adults. The US also has the greatest number of obese adults. Excess weight accounts for 4 million deaths worldwide, seventy percent of which are from cardiovascular disease. 

A new and large study from Sweden indicates that the risk of major birth defects increases proportional to the severity of a mother’s obesity. These patients are also at greatly increased risk of hypertension ( high blood pressure ) and diabetes. 

That gets us up to date with the news from the world of Obstetrics and Gynecology. 

Belated Medical Monday

I have just heard the best news about the Republican plans to replace the ACA (Affordable Care Act). Senate Republicans would like to postpone a repeal until……drum roll please …. the year 2020, when, you guessed it… another presidential election will take place ! I think this may be the GOP’s way of saying, “Sorry, never mind. We agree with President Trump who said, “Health care is hard.”." 

Especially now that the piper has started talking about getting paid… i.e. the Congressional Budget Office (CBO) has had it’s say, lawmakers on both sides of the aisle have come to realize that the costs of dropping the ACA provisions may exceed the costs of keeping them. 

There is however a need for action, and Senate Republicans will likely try to take action to stabilize premium costs. They will also to endeavor to continue federal insurance subsidies which help low income American with co-pays and deductibles. 

In other policy news, the Mexico City policy is back in place. This is the policy of withdrawing US aid funds from international organizations which provide reproductive services which include abortion. This is policy is meant to show the current administration's condemnation of abortion, and to curtail the incidence of abortion. However, Kenyan health care researchers have cited clear evidence from the past about what happens when the Mexico City Policy is in place. In fact, if these US funds are withdrawn from these types of health clinics, then many women go without health care and contraception and many more unintended pregnancies occur. Not surprisingly, under these circumstances, MORE abortions are actually performed. It seems impossible that the administration cannot be unaware of this. If this is true then it would seem they are really more interested in political posturing than abortion prevention or the health care of women. I'm going to speculate this this exact sort of thing will happen in that other part of the third world called Texas, where women's health care services have been severely restricted.

The Mexico City rule is also called the “ global gag rule” since all US funds can be withheld even if the clinic staff even speak of abortion.

Did you know that the current administration proposes not only to cut coverage of health care but also to health care research ? In his 2018 budget request titled “ A New Foundation for American Greatness”, cuts are proposed for the FDA ( Food and Drug Administration), the CDC (Centers for Disease Control), and the National Institute of Health (NIH) including the National Cancer Institute. How do you feel about this ? Tell your elected officials. 

Many on the red (Republican) side of the aisle continue to favor covering those with pre-existing conditions. Many of you may know of Jimmy Kimmel, the late night host and comedian. He has entered the health care debate in a most poignant way. His wife recently gave birth to a son with a congenital health defect. This defect required immediate very expensive and live saving surgery, which with insurance under the current Affordable Care Act, will be covered entirely. This baby's care coverage will not be subject to penalties for preexisting conditions, and there are currently no caps on insurance payouts under the ACA. Cases like this do become very costly, and in an environment where there are caps on what an insurance will pay, the Kimmel child might not get all the care he needs to live. So, legislators have spoken of health care plans which “pass the Jimmy Kimmel test". To pass the test, an insurance plan must cover all the care that such a baby would require. Many Republicans are coming out to favor plans which pass the Jimmy Kimmel test. See Jimmy’s moving monologue HERE:

http://ux.azcentral.com/story/life/tv/2017/05/02/emotional-jimmy-kimmel-discusses-baby-sons-heart-surgery/101189324/

In medical news, ACOG is trying to get the word out on normal anatomy. There is a disturbing rise in cosmetic surgery for the female genitalia, even in young women.  ACOG (American College of Gynecologists) is trying to educate patients and clinicians about the considerable variation in normal anatomy. They are also cautioning against so-called vaginal rejuvenation surgeries and other procedures which can have serious complications. One has only to look at the high costs of such surgery and the lack of insurance coverage of it to know that it is simply a moneymaking ploy used by unscrupulous gynecologists. 

In the “ we already knew this” department, a new study has come out reiterating that domestic violence is more common in pregnancy. Everyone needs to be aware of this. 

In the "you have some control” department, new research indicates that even one 10 ounce alcoholic drink may increase your risk of breast cancer- by nearly 10 % in post menopausal women ! The same study also shows that vigorous exercise reduces the risk of breast cancer. Worried ? Stop drinking and start exercising. 

It has now been well established that the HPV vaccine works to prevent genital warts and reduce the incidence of cervical cancer. The new revelation is that for kids under 15, only two rather than three doses are needed. 

Do you snore ? If you do, go get evaluated, regardless of your age. It is clear that sleep apnea increases risk of cardiovascular disease. New research also indicates that it complicates pregnancy, increasing risks of gestational diabetes and preeclampsia. 

Bed sharing with newborns increases risk of SIDS ( Sudden Infant Death Syndrome). A new program which includes face to face education and distribution of baby box kits has been shown to be effective in reducing the incidence of bed sharing. Baby boxes provide a separate space for baby with a flat mattress and a firmly fitted sheet. These boxes, as opposed to a bed or crib with lots of blankets, toys and fluff, are much safer places for baby to sleep. 

Stay tuned for next week’s Medical Monday and thank you for your patience ! 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

This week, the health care sector spent most of its time digesting the health care policy news from the end of last week. Reactions are coming in regarding Theresa Manning, Trump’s head of Title X family planning program. Here is a woman who criticizes the American College of Obstetrics and Gynecology (ACOG) on its endorsement of Plan B, the morning after pill, and who openly claims that contraception doesn’t work. 

Did you know that 22% of pregnant Texans under 18 have had multiple children ? Texas, the State recently enacting several curtailments to women’s reproductive services, is now grappling with it’s varied distinctions such as having sky high maternal mortality rates, and the highest repeat teen pregnancy rates in the Union. In a near comical about face, Texas is now considering a bill to provide free contraception to minors without parental consent. They have just now figured out this will reduce maternal morbidity, mortality, abortion rates and Medicaid costs. WOW. 

Reactions at a town hall meeting on New Jersey were quite clear, as participants boo’d their elected Senate Representative Tom MacArthur as he explained that rape victims could potentially be excluded from coverage. Talk about adding insult to injury. 

Pregnancy stands to be much more expensive under the ACHA. Those with prior Obstetrical complications such as C sections may fall under preexisting conditions and be charged exorbitant premiums. 

Senate Conservatives plan to drop millions of adults from Medicaid, which they say will reduce health care spending. They had originally said that tax credits instead would help people pay for health care, but now they wish to limit those on the fear that some may use their tax credit cash to pay for abortions. Paranoid much ? Moderate Republican Senators wish to keep the Medicaid expansion, citing it’s many benefits to their States. 

The Congressional Budget Office still appears to have teeth. They are the nation’s bean counters and they have yet to weigh in with REAL FACTS not #alternativefacts on how much the current administration’s ACHA (American Health Care Act) health care proposal will cost. This will include not only the cost of the insurance, but the uncovered health care costs incurred by those who lose their insurance. Polls show support of the ACHA is waning, and is down to around a third of Americans. 

A new study has shown that the credit card debt jumps for women but not men after a year of major medical expenses. Combine this with the fact that women have, on average, 20 % less income and spending power compared to men. Still ? 

As the weather gets warmer, Zika is back in the news. The CDC is now recommending all women at risk for Zika get a baseline Zika blood test. Once pregnant, they are to be retested every trimester. The CDC anticipates that this proactive schedule of testing will unearth many more cases of Zika this year. 

Hepatitis C has tripled its incidence between 2010 and 2015. Federal officials feel that the heroin epidemic is driving this. Among pregnant women, the infection rate has doubled. 

Perhaps in response to all the anti-contraceptive politics or perhaps for a variety of other reasons, the use of LARCs (Long acting reversible contraceptives such as IUDs) has increased seven fold between the years of 2008 and 2013. These are considered very good but still  underutilized methods. 

A new study presented at the annual meeting of the Association for Research in Vision and Ophthalmology states that marijuana smoked by pregnant women could damage the retinas of unborn children. The study utilized an animal model which showed this effect. 

Research presented at ACOG’s recent annual meeting indicated that patient information presented on Society Websites is too advanced for patients. These education materials do not meet the so-called health literacy standards, which are meant to ensure that information reaches it’s target. This is of particular concern to me as medical writer whose aim it is to convey information to a lay public and to my patients. 

What do you think ? Would you rather information be a little too simple or a little too complex ? It is quite hard to get it just right. 

Stay tuned for more breaking news next week on Medical Monday. 

Medical Monday: Breaking News from the World of Obsteterics and Gynecology

Most of you know by now that the House narrowly approved the American Health Care Act (ACHA) by a vote of 217-213. No Democrats voted for the bill and 20 Republicans broke rank and voted against the bill. The bill's future is less certain in the Senate where it will almost certainly be modified. While this represents a legislative victory for the Trump administration it is by no means an indication that the bill is sure to pass.

A true estimate of what this bill would cost is lacking. On first glance there are some savings, but a lifecycle accounting by the Congressional Budget Office has yet to be done. For example, those that lose their insurance under this new bill will cost the government less for their insurance but perhaps more in the long run due to the uncovered care that they receive in emergency rooms.

What is this likely to mean to you? Certain people who have employer sponsored insurance could have lifetime limits on their coverage. Plans may be able to be purchased which exclude mental health or maternity care. The American Healthcare Act will cut off funding to Planned Parenthood. Planned Parenthood delivers reproductive health care and other services to 2.5 million people annually. Pre-existing conditions may come back into play. Rape and domestic violence are considered preexisting conditions and thus care for those problems may not be covered under the ACHA.

Aside from the ACHA, a new executive order allows organizations to avoid the contraceptive mandate currently in place through Obamacare. 

The legislative chair of the American College of Obstetrics and Gynecology Dr. Leah Kaufman has written that this new AHCA is a particular disaster for women, citing astronomical costs for insurance that would cover women’s concerns such as pregnancy or breast cancer. 

Trump has named Theresa Manning as deputy assistant secretary for population affairs for the Department of Health and Human services. Ms. Manning is a former anti-abortion lobbyist for the National Right to Life committee and opposed both abortion and birth control. She will be responsible for supervising the Title X program which administers contraception, paps and preventive health services for low income women. Manning is infamous for her statements that abortion causes breast cancer, and that contraception doesn’t work. 

In the medical news department, research presented at the CDC (Centers for Disease Control) indicated that babies exposed to opioids in the womb are more likely to be in need special education services. 

In the good news department, yoga appears to relieve menstrual cramps and PMS. A review analysis of 15 different studies reveals that a regular yoga practice is associated with reduced pain and PMS with periods. 

Unfortunately, troubling policy news dominated this week. But Science marches on. Stay tuned for more breaking news from the world of Obstetrics and Gynecology. And by all means, contact your elected officials with your views. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The GOP has confirmed that they still do not have the votes to pass a rewrite of the Affordable Care Act. More particularly, Congress could not compromise their efforts to prevent a government shutdown by complicating matters with healthcare. Thus, the government has stayed open at least for another week.

The lack of ability to bring a proposal to the floor demonstrates yet again the deep divisions within the GOP on the issue of health care. It is interesting to note that the only subgroup within the GOP to endorse the current proposal is the far right House freedom Caucus.

Physician leader organizations have again jointly written to Congress this last week criticizing the latest iteration of the American Health Care Act. The primary concerns addressed in this letter were two. First they criticize allowing states to scale back “Essential Health Benefits". Secondly, they voiced concerns about the possibility that those with pre-existing conditions will again be discriminated against.

Meanwhile Democrats continue to characterize the Trump administration's efforts in healthcare as those which sabotage women's healthcare across the board: not only reproductive rights including contraception, but also access to general health care including cancer screening like mammograms and Pap smears. It has also been noted across both sides of the aisle that the Trump administration seems to be disproportionately withdrawing health care support for the  the poor.  There is also concern that the GOP healthcare plan will weaken Medicare. Is this for these reasons that centrist Republican Governors and Representatives balk at supporting his proposals since they know they will shift a bigger financial burden onto their states. This would be true since states would pick up the tab for the care of these populations. This would even be true if they do not pick up the tab, since without regular care, the uninsured will simply come in on an emergent basis, which is especially costly. Then these unpaid medical bills are indirectly covered by the rest of us, those who self pay or have private insurance. Thank you, federal government.

We pay for the underserved populations via our taxes through federal programs like the Affordable Care Act. Or, we pay if the States do not or cannot pitch in for their medical care. I would rather pay for a program which allows people to get preventive care, early diagnosis and treatment, simply because it is right, and also because it prevents human suffering, and because it is far cheaper in the final analysis. 

Case in point is the recent situation in Florida. The Florida House passed legislation last Wednesday requiring able bodied low income Medicaid recipients to meet new work requirements to keep their healthcare. This excludes people with disabilities, the elderly and children as well as those who have documented medical reasons to be off work. This sounds like a great idea, right? The purpose of the bill was to save the state of Florida money, and perhaps to engender responsibility. However, opponents of the bill expect that these requirements will actually result in a partial exodus from the rolls of Medicaid since not all current Medicaid recipients will comply with the new requirements. Opponents of the bill believe that as people come off the Medicaid rolls, the actual healthcare costs for this population will increase since they will once again utilize hospital emergency rooms for their emergent and non-emergent needs.

As a reminder, in our country, uninsured people are never turned away from the emergency room for the inability to pay or for the absence of any form of insurance. The care the uninsured receive is in every way standard and is in effect paid for by those with medical insurance and those who pay their own bills.

In a good policy news department, a forward thinking Republican senator from Omaha Nebraska, Joni Craighead, has sponsored a Nebraska bill which would require doctors to notify women if their mammogram reveals dense breast tissue. This is because dense tissue signifies higher risk of developing breast cancer. It is also the because dense breast tissue requires more and sometimes different imaging to diagnosis abnormalities.

In how-can-you-not-realize-this department, the Journal Birth has published new research on the risks of home birth. Researchers reviewed data for more than 47,000 home births overseen by midwives. Expectant mothers whose babies were breech or those who were attempting vaginal birth after cesarean section “may fare worse trying to deliver outside a hospital". In particular the study revealed that “risk of fetal death is 8 to 10 times higher for a home delivery with these risk factors”. This is death we're talking about here. 

A new survey by the College Health Association has revealed that college women tend to choose less effective forms of birth control such as condoms or pills, rather than IUDS. Cost and access to these better methods are thought to be the explanation. 

In the incredibly creepy department, a new form of reproductive violence against women has come to light. A new study in the Columbia Journal of Gender and Law has discussed “stealthing”. Stealthing involves a man removing his condom during sex without the knowledge or consent of his partner.  Women are then at risk for pregnancy and sexually transmitted infections. What do men possibly get out of this ? A survey of online forums show that it relates to a a belief about a male’s “natural” right to dominance and authority, to “spread his seed”. Although victims are commonly confused by how to describe what has happened to them, it is a form of sexual assault, i.e. rape. Switzerland has already established a legal precedent for convicting this as rape. 

In the “ finally” department, the FDA ( Food and Drug Administration) has finally spoken out against unproven cancer treatments being hawked on the internet. They have called out 65 bogus products that not only have no proof, but also that may cause harm. They also mention that patients often believe these are substitutes for traditional therapies. 

Studies of general medical conditions are now known to greatly underrepresent women and minorities. This has important implications, since the results of those studies on topics as important as heart disease, cancer and diabetes may not be as relevant to women and minorities. 

One more tool has been added to the global toolbox used to fight post partum hemorrhage. It is called Tranexamic Acid. It reduces death from bleeding about 20 percent and is less than a dollar a dose. It is meant to be added to the other usual methods of preventing and treating hemorrhage, such as massage, draining the bladder, pitocin, cytotec, and methergine. The clinical trial to producing this information involved 20,000 women in 21 countries. It was funded by Wellcome Trust, Pfizer, Britain’s health department, and the Gates foundation. Tranexamic acid’s brand name is Lysteda, and interestingly, it is produced by a separate drug company, Ferring Pharmaceuticals. If you have a little time for extra reading, take a detour and read about the American British Pharmacist Sir Henry Wellcome HERE. 

Stay tuned for more drama from the world of Obstetrics and Gynecology next week, on Medical Mondays. 

Belated Medical Monday: Breaking News from the World of Obstetrics and Gynecology

In policy news, things are moving at a slower, more measured pace. Moreover, the policy pendulum is swinging back to a more moderate place. In a move striking many as too little too late, the House GOP has proposed adding $15 billion to their now failed ACHA (American Health Care Act) making it more palatable to centrist republicans. This money would be pad to reimbursing health insurance companies for high cost patients. The intention is that this would help states reduce health insurance premiums for clients starting in 2018. The Kaiser Family Foundation has estimated that health insurance premiums will go up for the average ACA (Affordable Care Act) client by 19% if federal subsidies are withdrawn. Even with this 15 billion dollar amendment, the GOP did not have enough votes to pass their bill, and now Congress has adjourned for spring break recess. 

According to the Gallup poll, the majority of Americans now support the ACA. This is now the case for the first time since the ACA became law seven years ago. Though 55% of Americans now support it, many feel it could be improved. Centrist Democrats, calling themselves the “ New democrats”  and moderate Republicans,  “the Tuesday group”, are beginning to work with one another on small feasible improvements to the ACA which could benefit everyone.

Senator Bernie Sanders has promised to propose a bill for a single payor system, the so-called “ public option”, also known as “Medicare for all”  in 2018. 

Sixteen State’s Attorneys General have filed an Amicus brief against a new Ohio law which prevents health care providers who offer abortions from receiving any federal funds for any services. A US District Judge in Missouri has reversed a similar law in Missouri. 

In other abortion news, the 2013 Texas House Bill 2 required doctors to have admitting privileges in order to provide abortions. It also required them to do so in ambulatory surgical centers. Finally, it decreased the limit from 24 weeks to 20 weeks. The first two requirements put many midlevel providers in office settings out of business. About half of all abortion providers were put out of business. 

A new study in JAMA, the Journal of the American Medical Association, looked at the changes in practice since this law has taken effect. It turns out there were 20 % fewer abortions performed in that time frame. It also turns out that the abortions performed were done at a later gestational age. The researchers also calculated that an increased umber of abortions were performed illicitly. 

In medical news, the WHO (World Health Organization) has data indicating that fully 10% of all deaths worldwide are due to smoking. The number is believed to be underestimated since the effects of second hand smoke have not been accounted for. 

Death rates from the main types of cancer for all types of people have declined between 2010 and 2014. The decrease washout 2 %. 

In other good news, TDAP vaccine given in pregnancy is associated with lower rates of pertussis in babies later. (surprise ! ) 

Looking back at Zika, new data has shown us that 10% of women with Zika infection in pregnancy had a baby with a serious birth defect. The number may be higher since not all babies born to mothers with Zika have been given neuroimaging. Also in Zika news, a vaccine under development is progressing to phase two testing.  

In other vaccine news, according to the CDC, as of 2014, about 42% of all people carry the virus. A large new Scottish study of 20,000 women has shown that the HPV vaccine has been associated with a 90% fall in the prevalence of the virus.

Stay tuned for more breaking news from the exciting world of Ob/Gyn here, next week on Medical Monday. 

Thanks for your patience with my delay during Passover ! 

Here is may first ever angel food cake, made gluten free from scratch. It is served with a dairy free chocolate ganache, lemon curd, and cherry berry sauce. 

Belated Medical Monday: Breaking News from the World of Obstetrics and Gynecology

By now the whole world knows that Trumpcare version 1.0, the American Healthcare Act (ACHA) has failed. For now, Obamacare, the Affordable Care Act (ACA), remains the law of the land.

This last Friday, the ACHA bill went to the floor of the House for a vote. However, all day negotiations proved fruitless to bring over Democrats or close the deep divisions between House Republicans. House Republicans broke rank with the President, but did so in two camps. First those on the far right “ The Freedom Caucus”, withdrew support because they felt the bill was still too costly and still too much like Obamacare. Moderate Republicans withdrew support because the ACHA gutted federally funded Medicaid and is widely believed to lead to the loss of insurance for a great many people, putting that burden on the States. Paul Ryan, recognizing the tally, pulled the bill before the vote. 

House Speaker Paul Ryan has indicated the GOP will keep working on heath care. One little publicized option is for the Whitehouse to sue to stop the Fed from paying insurers for work done under the Affordable Care Act. This tact was going on before the ACHA was brought to the House. Their argument is that these contractual payments from the Fed to insurance are invalid and illegal. 

One of Trump’s major campaign promises was to reform healthcare, indeed to provide “universal coverage”. Progressives favoring Universal Coverage may attempt an uneasy alliance in the service of this goal. Senator Bernie Sanders plans to unveil such a proposal entitled “ Medicare for All “. 

Policy news is moving at light speed and I recommend everyone start reading it from various reliable sources. I also recommend people familiarize themselves with their elected representatives and give them and their staff regular meaningful input. 

On to actual medicine. 

A new study from the Journal of the Academy of Nutrition and Dietetics indicates that most American women do not eat a healthy diet when they are pregnant. This is something we see in clinic on a regular basis. It is worth noting however the many women believe that they are eating healthy diet, even though they are not. These are well-intentioned people who have been taken in by advertising or who are victims of their busy schedules. Unless the physician or nurse midwife takes a detailed dietary history they will not know how their patient is really eating. Merely asking the person whether or not they eat healthy is not enough. People generally say they eat healthy and people generally say they are active or fit. That is because they believe it to be the case. Until people have objective definitions in front of them they cannot reliably answer these questions. Doctors take important shortcuts if they do not delve into a reasonable amount of history taking detail. When patients get specific explanations of exactly what we mean when we say "eat healthy", they're much more likely to do so. One of the problems of course, is that many doctors do not know precisely what it means to "eat healthy”. 

Four prior commissioners of the Food and Drug Administration (FDA) have produced a joint letter warning Congress about the legalization of importing drugs from other countries. Certain members of Congress have indicated that they would support this in an effort to reduce drug costs. In particular, the commissioners emeriti have warned against counterfeit, substandard and contaminated medications, since standards from other countries may not be adequate.

Pregnant women with HIV have a better chance than ever of avoiding transmission of their virus to their children. Preventive treatment including retroviral drugs given in pregnancy account for this progress.

In other viral news, a new gel treatment for genital and perianal warts is under study. These are caused by the human papilloma virus. The treatment is based on nitric oxide. Stay tuned for more on this nascent therapy.

Also regarding human papilloma virus, the American Society of Clinical Oncology has issued global statement regarding the primary prevention of cervical cancer. They recommend that all girls ages 9 to 14 receive two doses of the human papilloma virus vaccine also known as Gardisil. In the last few years there has been definitive evidence that Pap smears combined with this vaccination reduced the incidence of cervical cancer. The vaccine is also available for boys of the same age group.

Yet another study has demonstrated that exercise during pregnancy is safe and beneficial. This most recent study published in the Journal of the American Medical Association is meta-analysis of studies with more than twenty five hundred pregnant women. This is in line with ACOG (American College of Obstetricians and Gynecologists) recommendations which indicate "women without major medical or obstetric complication should get at least 20 to 30 minutes of moderate intensity aerobic exercise… on most days of the week."

In the concerning department, the FDA (Food and Drug Administration) has now linked anaplastic large cell lymphoma (ALCL)  to breast implants. This disease is a rare malignancy in the immune system which is statistically linked to breast implants, particularly those which have a rough versus smooth surfaces. The FDA has issued a statement indicating that women with breast implants have a very low but increased risk of developing ALCL compared to those who do not have breast implants. It is worth remembering that a statistical link does not prove causality. Concerned patients should speak to their plastic surgeon about this matter.

In other cancer news,  new research indicates that breast cancer gene testing is underutilized in America. A simple history in the caregiver’s office can identify whether or not a patient is at high risk of having abnormal genes, i.e. breast cancer gene mutation, or BRCA. Women with two first degree relatives such as a mother or sister are at high risk for having an abnormal gene and should explore the possibility of testing. Those patients with close relatives with any cancer should make sure their caregiver is aware of it. 

New research coming out of the Cancer Genome Atlas Project and the Cancer Research UK Database have indicated that only about a third of cancers are due to a special inherited genetic mutation. This means that two thirds of cancer-causing mutations arise spontaneously and are not able to be inherited by one's children.

We conclude with the good news department. A new device called the Alexis retractor is being tested across the world. Preliminary indications in Europe show reduced infection rates and reduced post operative pain after Cesarean section. 

Finally, many States are following another European lead and introducing baby boxes. Currently Americans put their newborn babies to bed in a wide variety of ways. However, clear research shows that the incidence of SIDS (sudden infant death syndrome) can be significantly reduced if babies are placed on a flat surface on their backs, head uncovered, in a special sleep sac or a one piece sleeper, and WITHOUT any blankets, swaddling, bumpers, padding or or toys. The sheet on the firm mattress should be fitted. The baby box programs are designed to provide all this teaching as well as an actual  baby box and mattress. For those who are not aware, the baby sacs are like insulated zip overalls with a closed bottom, which allow babies to move. They are not to be confused with swaddle wraps, which are also associated with SIDS. Babies typically wear a shirt and a diaper with it. Very cute inexpensive ones can be obtained at Ikea, Target and online. 

Here is an authoritative link from the NIH for those who want to learn more: 

https://www.nichd.nih.gov/sts/about/environment/Pages/look.aspx

Our photo for today's post was brazenly lifted from the pages of the National Institute of Health linked above. 

Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology.

Medical Monday: Breaking News from the world of Obstetrics and Gynecology

It is true that some of us were wishing the American Health Care Act would just go away. Friday has shown us that sometimes wishes do come true. 

Medical Monday per se will be delayed one day in order to better report on this momentous news of late Friday. We will want to see reactions from all the various sectors on this important development.

The Affordable Care Act, also known as Obamacare, represented progress. It gave us the individual mandate, requiring us all to have insurance or pay penalties. It gave us the contraceptive mandate, which data clearly shows saves money and unplanned pregnancies. It gave us subsidies and more.  However it is unclear how sustainable it will be since it is costly. The new more fiscally conservative administration, at their very best, could scrutinize the program further for cost saving measures. 

While we are wishing, I will put out some of my best thoughts on the matter. 

"Best Practices Health Care Act" 

(This title implies policies will be driven by data, and not politicians.) 

1. Keep the individual mandate and make the penalties stiffer. (Similar to auto insurance.) Give it real teeth. 

2. Keep the contraceptive mandate. This means birth control will have no copays. Drive prices of contraceptives down by allowing the government to negotiate drug prices. 

3. Separate abortion services out of Planned Parenthood and continue to fund the great preponderance of what services remain. 

4. Keep children on policies until 27. Consider allowing even older family members, but raise premiums accordingly. 

5. Charge increased premiums for risk factors ( similar to life insurance) such as smoking, alcohol use, obesity, drug use. Also charge increased premiums for high risk sports such as skiing, paragliding, horseback riding, etc. Charge increased premiums for those with bad driving records. 

6. For Medicaid recipients, require small copays and, for the able bodied, work and/or service. 

7. Government may negotiate prices on all drugs. 

8. Fully fund preventive services without copays, i.e. encourage and reward prevention in every possible way. This would include annual exams, cancer screening, dexa scans (screening for osteoporosis or bone thinning) and vaccinations. 

8. Create a combined sliding scale of subsidies for the poor and tax credits for the rich. 

9. Keep low risk and high risk patients together in one pool. 

10. Reward participation (lower premiums) in accredited health programs. 

11. Manage medical malpractice expenses aggressively, keeping as many health care dollars out of the hands of lawyers as possible. This might involve caps on lawyer fees, and caps on malpractice awards. This might mean mediation is required before litigation. 

This is just a start of ideas, that I, as a physician, think we need to think about. Stay tuned to see what the rest of the world thinks about this development.