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

Policy News

This week, and maybe from here forward, policy is becoming more State based. A few blog posts ago, I highlighted the fact that the ACA (Affordable Care Act) is run differently in different States. Some States run it entirely themselves, with money coming from the Fed, while others have the Fed run it. Other States use a hybrid model. Many States are looking at potentially rising health insurance premium rates, which will be necessary to keep programs funded, and are beginning to add State based funds to defray the severity of the increases. In other words, they are providing their own insurance subsidies to their citizens who use the ACA for their health insurance. 

Many States are turning to work requirements for Medicaid Recipients. I believe the idea there is to incentive work and the earning of money , with which ACA or better insurance can be purchased. It is both to reduce the burden of Medicaid patients on a State by causing fewer people to actually need Medicaid, either in the short run or the long run. 

There are currently work requirement proposals in ten States, which could potentially impact 1.7 million. As an Obstetrician Gynecologist, I would advocate for separate work requirement algorithms for pregnant women versus others. 

The judicial branch of our government is starting to weigh in on the Trump administration’s changes on the way health care is being delivered in this country. An Ohio law blocked funding to 28 Planned Parenthood clinics. However, a Federal court has blocked this law, saying that while the State may prefer “ childbirth to abortion” defunding planned Parenthood has little to do with that question since this particular money is not used for the support or performance of abortion. In barring this law, many primary care health services will be safeguarded. 

There are several lawsuit against this administration’s defunding of the Teen Pregnancy Prevention Program. A Federal Judge in Washington DC has declared the termination of the program unlawful and ordered the DHHS, Department of Health and Human Services to move forward again with the application of four such applicants within the program. 

Medical News 

If a pregnant woman is a risk for gestational diabetes, her physician may ask her to improve her diet and be more active. It turns out that those who made the changes have better glucose regulation even one year after baby is born. 

Coming from the other direction, we have the following report from the esteemed Journal Lancet. It seems that the environmentally determined health of both mother and father play greatly into the ongoing health of future not-yet-conceived babies. Each parent’s condition, whether well nourished, stressed, obese or fit, has influence on the cells and the DNA from which future children will be made. This us believed to take place through a process called epigenetics in in which an indivudual’s present day physiologic circumstances feed make and alter the expression of their genes and the genes of their germ cell lines (eggs and sperm). The article goes on to conclude that it points to a whole new level of preconceptual counseling which we must do. 

COPD (chronic obstructive pulmonary disease) usually related to smoking, now kills more women than men in this country. The days of “Virginia Slims” a TV ad brazenly directed toward women, are coming back to haunt us. I try to to remind patients that tobacco related poisons are much harder on women than men, and that smaller people in general get a higher relative dose. 

Many breast cancer patients lose their hair, if not from chemotherapy, then more mild so from anti cancer hormone medications like tamoxifen. New research says Minoxidil can help reverse that. 

Newsflash: the USPSTF - the US Preventive Service Task Force feels there is now enough evidence to recommend exercise to prevent falls in those over 65. And while I jest at the commonsensical nature of this announcement, falls are a major concern for most people over 65 and can lead to serious and life threatening injuries. No matter what age you are now, consult with your caregiver to see how you can attain optimal health and fitness for the present and the future. Whatever it is, whether seated stretching or training for an Ironman, start now. You will not be getting any younger. That is, unless you get more fit. 

A recently reported study shows IUD (Intrauterine Device) use has increased in recent years through 2013. This is believed to have been related to dropping out of pocket prices. I suspect newer studies will show use has increased even further with many women chasing long acting methods for fear of losing affordable birth control coverage. 

US maternal mortality has been increasingly in the news. Despite all the press, maternal mortality continues to rise through the present, and is concentrated in certain areas of the country, most notably Texas. Many correlate the most severe statistics with poverty and discrimination. Of late, many also finger the defunding of primary care clinics, particularly those like Planned Parenthood, which served more real and lower income populations. There are, at present two Bipartisan pills stuck in Committees which would support the formation of state committees to track and prevent the phenomenon. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, here, next week, on Medical Monday. 

Medical Monday : Two Week Catch Up

Happy Easter and Happy Passover. We have two weeks to cover. Thanks for reading ! 

Policy News

Much of the National Health Policy News this week deals with contraception and reproductive health. Can anyone remember any time in this or any other country when these private matters were ever so much on the national stage ? The politically conservative aspects of my nature questions why this degree of government intervention in private lives is necessary. My medical qualifications and medico-legal experience cause me to classify some of this meddling as practicing medicine without a license. 

Title X is a federal grant program whose purpose it is to promote positive birth outcomes and healthy families. It provides grants for family planning and health services. So here’s my first question: Why is it not run by health care professionals ? Trump administration officials are now contemplating new wording which would add additional criteria for clinics to receive Title X funding, namely the provision of primary preventive services. Sounds good right ? Well many clinics offer only reproductive health services. These clinics would have to expand or close. This measure seems like just another way of closing family planning clinics.  Now whether pap smears would qualify as preventive health is unclear, or whether paps would be classified as reproductive health, I don’t know. 

Texas is challenging the federal government’s withholding of funds for its family planning programs. They were withheld several years ago based on the fact that these providers, many of them through Planned Parenthood, also provided abortions.

Planned Parenthood itself is challenging the Federal Government on its withdraws of funds from the teen pregnancy program. Between this and two other plaintiffs, the Department of Health and Human Services has partially and temporarily restored some of the funding until litigation can be completed. 

Idaho has failed to solve the problem of insurance for those whose income falls between Medicaid and the Affordable Care Act coverage criteria. A proposal called Plan First Idaho would have funded family planing services for women in the gap. My question is, what rocket scientist designed the State’s the two programs such that their income qualifying criteria do not meet seamlessly ? This is a problem of their own making and it needs solving. Republicans in the Idaho House stalled this measure. 

Idaho Governor “ Butch” Otter has approved a measure by which prospective abortion patients must a told about “ abortion reversal” a procedure that does not exist. Additionally, he has signed legislation which will require abortion providers to collect personal and demographic information which, in de-identified form they intend to make public. I don't know what they think this will accomplish, but I have a feeling it may backfire, since they will be able to see how many and how diverse a group of women utilize the procedure.

The Supreme Court is hearing a case between the State of California and a group of "crisis pregnancy centers”, an actual chain of 130 outlets run by “ The National Institute of Family and Life Advocates”. These centers are anti-abortion counseling facilities, however they are licensed as family planning providers. California has a law requiring that all licensed family planning facilities to post notices of the availability of free or low cost birth control and abortion services and they are challenging it. They are arguing that this posting requirement violates their free speech.  So far the Court has expressed concern that these clinics not be singled out from other clinics. California has argued that their staff, many of whom are not medically qualified, present medical misinformation as truth, all to the end of dissuading patients from abortion. Apparently theses non-credentialed counselors actually wear white coats. 

Along with the opioid epidemic has come a hepatitis C epidemic. Kentucky, having seen a surge of the disease, has passed a law now requiring all pregnant women to be tested for it. Hepatitis C used to be very hard to treat. However, patients have much more hope nowadays due to the availability of effective therapy. 

Missouri has expanded Medicaid for pregnant women in drug abuse treatment. Their continued coverage will be contingent upon them staying in treatment, and could under those conditions, be continued up to 12 months.  

And now for more of a purple to blue state review:

Florida is considering a bill requiring HPV (human papilloma virus) vaccination to be required as part of the vaccinations required of children attending public school. Human papilloma virus causes multiple illnesses most notably cervical cancer and genital warts, and the vaccine has not demonstrated any conclusive evidence of harm.

It is interesting to note that physicians are not prescribing HPV vaccine equally for female and male children. Doctors recommend the vaccine twice as often for girls as they do for boys. This puts the boys at increased risk for HPV disease, and puts all their future partners at increased risk too. 

Mississippi passed a law banning abortion after 15 weeks Of course this is unconstitutional based on Roe V. Wade which is still on the books. A Federal Judge over turned Idaho's ban. 

New Hampshire has passed a bill which will allow pharmacist to prescribe birth control. No doctors visit will be necessary. The medical establishment has concluded that vast majority of the birth control methods are safe for the vast majority of women. They certainly are when compared to pregnancy for those same women. Authorities believe this will eliminate yet one more barrier to contraception. Utah signed a similar law into place earlier in the week. 

On the other coastline, the state of Washington now has a bill that will require insurance to cover contraception, abortion and maternity care. Additionally, after the first of the year, all contraception has to be co-pay and deductible free. This includes voluntary sterilization. 

The new budget has failed to shore up the ACA ( Affordable care Act) marketplaces. States will have to tighten their belts and work on their budgets one by one. 

ProPublica has reported that the “US is the most dangerous country in which to give birth”. States all over the US are creating programs to quantify and address the problem of maternal morbidity and mortality, even as the Federal government under Trump is dismantling reproductive and maternal health care piece by piece. 

Do you ever get the feeling that the various States in America are becoming like the countries of the European Union with different values, cultures budgets and laws ? 

Medical News: 

Obstetrics: 

Striking research findings presented at Lancet Global Health conference have shown that the death risk is double among pregnant women who are anemic compared with those who are not. The lead study author also found the correcting anemia is not a sufficiently high enough priority among physicians. 

Research presented at Diabetes UK conference has shown that excess weight gain incurred during pregnancy by  gestational diabetics is associated with greater risk of cesarean section.

Women who exercise in pregnancy have shorter labors. This interesting news was published in the May issue of European Journal of Obstetrics and Gynecology and Reproductive Biology. The study group attended a professionally led session of moderate exercise three days per week. Labor was shortened about one hour, mostly in the first stage, or dilating phase. ACTIONABLE ! 

Children who were breastfed exclusively for at least 6 mores were less likely to become overweight to obese than their counterparts. The conclusions were drawn by analyzing over 38,000 records from children South Korea. The finding were presented at the Endocrine Society Annual Meeting. 

Gynecology/General Medical News: 

There may be a male birth control pill on the horizon. Research at the Endocrine Society's annual conference has presented information on a new male birth control pill called DMAU. It contains androgen and progestin,  which is analogous to the contents of the female birth control pill, estrogen and progestin. Once daily tablets appear to be safe and effective. No period required. 

Menopause and aging in general is characterized by a loss of muscle mass and bone density as well as the deposition of fat. As suspected, the Mediterranean diet may have a positive impact on bone mineral density and muscle mass in postmenopausal women. The Mediterranean diet emphasizes the eating of high quality protein, large volumes of fruit and vegetables, healthy fats such as olive oil and a modest amount of complex carbohydrates such as whole grains. As a whole, the diet is lower in simple carbohydrates than the typical American diet and is also higher in protein and antioxidants.

There are now over 400 cases of a rare lymphoma which are linked, epidemiologically, to breast implants. Breast implants are not new. Lymphoma is not new. However our ability to collect and parse data is better than it has ever been. The FDA it's taken this ability and created a meaningful database for this type of information. While an association between breast implants and this rare lymphoma is being established through data collection, a causality between the two is not necessary implied. That said, nothing is more likely to lead us to understand the causes of this problem than amassing quality data about it. 

Federal funding support for cancers is disproportionately low for gynecologic cancers if you rank them by lethality. Cancer of the ovary and the uterus ranked near the bottom of the funding list. Contact your elected officials ! 

A new modification of the current device used for pap smears can identify cells from endometrial (uterine lining) and ovarian cancer. The investigational PapSEEK uses an analysis of 18 genes and analysis similar to that used in prenatal screening for Down’s syndrome to identical the genetically abnormal cancer cells. THIS IS SO COOL ! 

A new study on postmenopausal hormone therapy has shown that it does help maintain thinking and memory skills. This is the case IF it is initiated shortly after the onset of natural menopause. This study was presented in the Journal Neurology and was a high quality randomized controlled trial of 75 women between the ages of  42 and 56. 

In my mountain state, there is not a great deal of sunlight or seafood. As a result we have a high prevalence of vitamin D deficiency. New research indicates that vitamin D deficiency increases a post menopausal women’s risk of metabolic syndrome. Metabolic syndrome includes the unholy triad of diabetes, high blood pressure, and abnormal serum lipids ( cholesterol and triglycerides) which together increase cardiovascular risk. Vitamin D levels are checked by a simple blood test. Ask your doctor about this ! 

Stay tuned for more news from the exciting world of Obstetrics an Gynecology, next week, here on Medical Monday ! 

Medical Monday: Delayed Edition

POLICY NEWS 

The Department of Health and Human Services wants to expand funding for “ natural family planning” and “ fertility awareness” which are largely ineffective methods of timing based birth control. In other words, DHHS want Medicaid to begin covering visits where patients are told this is a viable method of contraception. In other words, the DHHS wants to spend your tax dollars on an ineffective, scientifically invalid method of birth control. Meanwhile the rest of the administration is working on dismantling the Contraceptive Mandate, the part of current insurance law which states that insurers must cover, without copay, real effective birth control. Additionally, the DHHS has announced it is moving away from “ comprehensive sexual education” which is evidence based, and instead will be using your tax dollars to teach “ abstinence only” which has been proven not to work. It is beginning to seem like the administration wants women to have more babies. Maybe they see this as stimulating the economy through having more consumers, I don’t know. 

California Judge Haywood Gilliam has stood up to the Feds determined to weaken the contraceptive mandate. He has blocked changes to the ACA in California, saying that he will not allow these changes “ transform contraceptive coverage from an entitlement to a benefit subject to employer discretion.”

Utah is writing law which will require radiologists to specifically notify women of dense breast tissue. In this warning they are to explain that screening is less effective, and that they may be eligible for other screening modalities. 

New Jersey has replaced Republican Governor Chris Christie with Democrat Phil Murphy. Governor Murphy has reversed 8 years of policy by restoring funding to Planned Parenthood and other women’s health organizations. He has also signed a bill expanding coverage for Medicaid coverage of family planning, prenatal care and cancer screening. 

DHHS is working on various plans to reduce the price of prescription drugs to consumers. Sounds good right ? However one of the cost control measures is capping the amount of prescription drug benefit that Medicare Recipients can receive. The other strategies include enabling as many as 5 states to collectively bargain with suppliers over prices. 

The administration is at it again, proposing bargain basement plans for people. In the words of Admiral Akbar, “It’s a trap !”. 

These plans are cheap, and some fear that consumers might not realize their limitations on coverage or pre-existing conditions. These plans which do not comply with the protections and coverage of the ACA ( Affordable Care Act) are a recipe for future disaster. They contribute little to the collective pot and cover little for their purchasers. 

MEDICAL NEWS 

In the important and alarming department, we have cleaning sprays. New research published in the American Journal or Respiratory and Critical Care Medicine has shown that the “regular use of cleaning sprays can have as much impact on health as smoking a pack of cigarettes a day." In this 6000 person study, “ cleaning even once per week was associated with an accelerated lung decline risk”. I will try to find out more about the types of cleaning agents used. 

HPV vaccine is still underused. Fewer than a third get their first dose by age 13, and fewer than half of all children are up to date on all their doses

In other vaccine news, a recent inventory of 400,000 births confirms that both influenza and TDaP vaccines are safe in pregnancy, and confer protection to both mom and baby. 

When we think of a heart attack, we think of an older man with check pain. However, women suffer heart attacks almost as much as men. However in women, particularly women under 55, symptoms may not be recognized since they are different than mens. These patients are more likely to have what is described as indigestion, shortness of breath, palpitations, or jaw pain. 

In related news, women’s heart attacks may have a different mechanism, coronary vasoconstriction, rather than the blockage from plaques that male patients often have. A new study confirms that among women with chest pain, and clean arteries, nearly 8% have scarred areas on the heart confirming that a heart attack occurred. 

About half of all breast cancer patient facing radiation heard “ frightening stories” about it. However after the therapy, only 2% agreed that the stories were true. 

Illinois has targeted maternal morbidity, specifically maternal morbidity due to severe maternal hypertension. A “quality initiative” specifying a “suite of interventions” was implemented. Participants qualified for the study by having BP at or greater than 160/110 (yikes!). Interventions included prompt pharmacologic treatment of maternal hypertension, specifically designed discharge education, and short postpartum follow up intervals. Severe maternal morbidity such as stroke as already decreased by 41%.

Stay tuned for more exciting news from the world of Obstetrics and Gynecology right here, next week, on Medical Monday. 

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

Policy News 

The Trump Administration will continue to use a bundled payment model for Medicare recipients. This means that the government will pay a certain lump some to cover all the inpatient and procedure related medical care given to Medicare patient rendered in a 90 day period of time. If the healthcare providers use less than that amount of money they can receive a bonus. This strikes me as a terribly perverse incentive. Hospitals and caregivers have every incentive to skimp on care so they can pocket the bonus. What if the amount of money allocated is not enough for all the care the patient needs within the 90 days? It is interesting to note that this bundled payment strategy was created under Obamacare (The Affordable Care Act or the ACA) and has been reincarnated in almost exactly the same form under the Trump administration.

Several women’s health organizations including the American College of Obstetricians and Gynecologists (ACOG), have instituted a program called"The Care Women Deserve”. Under this program, there will be an effort to educate all women regarding the health services to which, under the ACA which is current law, they are entitled, at little or no cost. Examples of these services include well woman visits, also known as annual exams, Pap smears, contraception, also known as birth control, HIV screening, mammograms and breast-feeding support. Not all women know that they are entitled to all these services.

The Trump administration has long tried to weaken the contraceptive mandate, the part of the Affordable Care Act which requires insurance companies to cover contraception without co-pay. They have received many legal challenges to these attempts. The Trump administration has paid out over 3 million dollars of taxpayer money to to settle these lawsuits.

For the first time in Medicaid's 50 year history certain states will be allowed to interpose work requirements on certain able bodied adult recipients. The National Health Law Center is preparing to challenge this in court.

Washington DC’s only pubic hospital has been closed due to quality concerns. 

The Wall Street Journal is reporting that the GOP is scaling back plans to reform the ACA and social security type programs. They are focusing on basic problems like funding the government. They are even talking about increasing the debt limit and reaching a compromise on immigration. Since when has the GOP been interested in increasing the debt limit ? 

Medical News 

Studies 

• Once again our own immune system is at the heart of a disease process. Evidence from a mice model suggests that the damage caused from Zika virus infection is actually from the mother’s immune response against the virus in the baby. This was published in Science Immunology. 
• A large retrospective study has indicated that pregnant women who take methylphenidate for ADHD have a higher likelihood of having a baby with a heart defect. 
•  A new study published in the Journal Birth looks again at Texas maternal mortality rates. Between 2011 and 2015, there has been an 87% spoke in maternal mortality. The worst has been in mothers over, 40 with that group having a mortality rate 27 times that of women under 40. This is felt to be related to increasing rates on chronic and under treated disease including obesity, lack of insurance and lack of health care. 
• A 172 woman study published in Menopause made the we-already-knew-this-department. They have shown that one year of postmenopausal hormone therapy prevented depressive symptoms more effectively than placebo. Postmenopausal hormone therapy is FDA approved for hot flashes and vaginal dryness, but not for mood disturbance. Maybe it should be. 
• The Journal of Asthma has published a study linking prenatal exposure to PCBs ( polychlorinated biphenyls) to asthma and upper respiratory infections and eczema in children. 
• A new study has indicated that women who work night shifts have a (gasp) 19% higher chance of getting cancer than those who do not work at night. This meta-analysis has shown that the risk is proportional to time worked at night, and that the risks  go up differently for different cancers. The most surprising is skin cancer with a 41% increase in risk. Next is a 32% increase in breast cancer, and an 18% increased risk in digestive cancers. Yikes ! I hope the exact reasons for this get figured out and dealt with ! 

We have a new department ! It is called the stupid and irresponsible department. Our inaugural feature is devoted to the TV show Black Mirror, whose writers decided to depict emergency contraction, aka “ Plan B” or “ the morning after pill” quite incorrectly. In particular, they portrayed a teen who took it as having nausea, which is not typical. A nurse in the show informs her she had taken it “ to terminate a pregnancy”. Basically the show confused the morning after pill with the abortion pill. The morning after pill is progesterone only, thus should not cause nausea. Plan B does not cause abortion of an established pregnancy. It prevents pregnancy. Thanks so much, TV,  thanks. 

Stay tuned for more exciting news from the world of Obstetrics and Gynecology next week here, on Medical Monday. 

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

As I step back and look through my last year of posts I am astonished to the extent to which politicians are getting deeply involved in the particulars of my profession, Obstetrics and Gynecology. This week's post underscores this in no uncertain terms. Is this really where we want government and politicians, right in the middle of a very specialized medical field, and right in the middle of the doctor patient relationship ? 

The New York Times has reported the the Trump administration plans to expand exemptions to the so called “ contraceptive mandate”. They are not abolishing the contraceptive mandate at this time. However, they are allowing employers to chose plans that do not cover birth control. These employers or insurers must be exempted on basis of “sincerely held religious beliefs”. 

It is my assumption that it is employers’ assumption that such plans which do not cover contraception are less expensive. However I feel entirely comfortable asserting that insurance companies know precisely where their dollars go, and they will not, for one minute, pass the savings on to the employer. That is because in about nine months after institution of this policy, there will be no savings. Seriously, do people really think that pregnancies and miscarriages will cost less than contraceptives ? 

As far as religious objections go, there are ostensibly several considerations. First, social conservatives have argued that the use of contraception encourages what they view as illicit or teen sex. This has been proven not to be the case. Moreover, they may object saying that contraception causes abortion. IUDs do act in part by preventing implantation of fertilized eggs, but they also act by causing cervical mucous to become viscous and block the cervical canal, preventing fertilization in the first place. So in this sense, a few fertilizations may take place which cannot implant. However, and critically, without any IUD or other birth control in place, as many as  25 % of fertilizations which do occur simply do not implant naturally, or they implant and naturally fail. Thus, with an IUD, a very small percent of fertilizations occur and do not implant. Without an IUD or other birth control method, 25 % of fertilizations fail and are lost, most before the period is even missed. In the end, there are many more natural abortions that there are IUD related abortions. If an abortion is an abortion, and one wants to minimize their numbers, one would certainly want to provide as much contraception as possible. A true anti-abortion advocate should espouse both IUDS and other forms of birth control, especially pills which prevent ovulation. 

But it seems those who are anti-abortion are interested in more than just preventing abortion. They are interested in legislating a world view and lifestyle. They see a world  where there is only one right way to live, and that those who live this way should have power over those who don't. I can only conclude this because of the “don’t bother me with the details” approach of much of the GOP on numerous scientific and medical issues such as contraception. If the GOP really cared about strengthening families, preventing abortion, and the health of infants and children, they would choose policies scientifically proven to meet these goals. ACOG ( The American College of Obstetricians and Gynecologists) has already come out against the bill since it is at odds with those goals. 

It becomes somewhat misleading to write so much about abortion policy since there are so many other pressing medical policy issue of the day. However, so much is happening in this area that it behooves me to report on it. For example, the ACLU (American Civil Liberties Union) has sued in Federal court in Hawaii challenging restrictions on the use of Mifiprex, the so-called abortion pill. They have argued that it should be available by prescription in a pharmacy. At present, a clinic or hospital visit is necessary. Particularly in the Hawaiian islands, access to clinics is variable. Mifeprex has been determined safe and legal, so ACOG has supported this suit. My concerns with pharmacy dispensing is that patients with positive pregnancy tests should have a reasonable idea of their gestational age before they take the medication, and that ectopic or tubal pregnancy not be missed. 

The House just approved the “Pain Capable Unborn Child Protection Act” which bans all abortions after 20 weeks. ACOG’s position is that a fetus cannot feel pain until 24 weeks. You just have to continue asking yourself, how do organizations and people formulate their opinions ? What data do they use ? Do they use data ? Would they know bad data from good data ? 

Forget alt facts. This next report shows us how far certain members of the GOP are wiling to go in their separation of politics from reality. Former Congressman Tim Murphy, a Republican from Pennsylvania, was a staunch anti-choice politician. However, he was recently caught telling his mistress to get an abortion. Think this is this height of hypocrisy ? Think again. Mr. Murphy promptly recused himself and resigned. Not Scott Dejarlais. This physician and Republican Representative from Tennessee circa late 1990s, called himself “pro-life”. However, he had multiple affairs with 3 co-workers, a “drug rep” and at least 2 patients ! At his divorce, he testified that he had supported his then girlfriend and now ex-wife to get two abortions. You would have thought he too would leave politics. However he has since been re-elected twice. The people have spoken and will get what they deserve. 

Finally, in a surprising turn of events, the Republican Governor of Illinois, Bruce Rauner, has signed a bill allowing Medicaid to cover abortions. He has stated that he does not feel women of different means should face different options. He has gone on record as a pro-choice Republican. 

Meanwhile the entire hurricane belt suffers under a burden of destruction and disease. There is a shortage of just about everything, from basic needs, to power, to medicine, doctors, and means of transportation to get all of it where it needs to go.  Shortages of pharmaceuticals in particular may be felt all through the US based on the increased need in the South. 

In medical news, we shift our attention to yet another case where beliefs seem to supersede science. Witness the practice of certain women of a more "natural" bent taking their placenta home to consume. It’s meat, right ? It’s even your own tissue, so what’s the big deal ? Most mammals do it. Modern women can have it various ways, but the most refined way is to have it “ encapsulated”. It turns out that “placentophagy" can make you and even your baby infected and sick, through pathogens (bacteria) that would have been killed by your own immune system, but aren't since they are separated from it and encapsulated into little gelatin capsules for swallowing. Moreover, the hormones in the placenta are NOT what you want after birth. The whole mechanism of uterine involution (contracting to prevent bleeding) and nursing is triggered by the expulsion of the placenta and it’s hormones. It is the expulsion of the placenta that changes you from pregnant to non pregnant. If you had complications in pregnancy like hypertension, you won’t get better until all your placenta and it’s hormones are gone. 

A new study has shown that those who drink four cups of coffee per day have a 64% lower  risk of early death. I would like very much to see that stratified by sex and age. Men do not have to worry about osteoporosis ( bone thinning) as much as women. Caffeine does thin the bones, and bone fractures in old age are a tremendous source of morbidity in older women. Women who are pregnant certainly should not drink that much caffeine. We ask our pregnant patients to limit their caffeine intake to 200 mg per day which is alot less than four cups. More than 200 mg per day of caffeine is associated with poor fetal growth. Whenever hearing results of a research study, ask yourself several questions. To whom does it apply ? Did they include women in the study ? What does this mean for women, or for a person like me ? 

Once again we have new evidence linking obesity with more than just diabetes and heart disease. A new report from the CDC (Centers for Disease Control) has indicated that “excess body fat accounts for at least 13 different kinds of cancer.  This study looked at over 600,000 people in the US in 2014. Obesity rates have increased even more since then. Results like this should change the way we think and teach about obesity. 

We have already mentioned the Southern United States in this post - the Hurricane belt. That same area is also know as the fat belt, also the bible belt. New data also shows that those in the deep south and midwest have higher smoking rates than the national average. In that area 22% of adults smoke, compared with 15% in the rest of the US. Could there be cultural reasons for the smoking and obesity ? 

A few years ago there was a bit of a scandal pertaining to a drug to treat preterm labor. Sold as a name brand, it was exorbitantly expensive. Generic, or even compounded, it was very cheap. It came down to FDA approval as to whether it could be sold as generic. First it couldn’t, then it could due to public and medical outcry, then it couldn’t again due to concerns about safety efficacy. However, now a new study published in JAMA Internal Medicine has indicated that the two preparations are equivalent. It will be interesting to see how long this data takes to get translated into policy, and we can once again buy cheap generic and have it be covered by insurance. 

In the good news department, breast cancer rates are declining. The American Cancer Society reported that breast cancer deaths increased through 1989. Thereafter, they have been on a steady decreased, altogether down 40 % since 1989. This attributed to better treatments and medications. 

Stay tuned for more fascinating news from the world of Obstetrics and Gynecology, next week, on Medical Monday.

Medical Monday: Delayed Edition

Policy has marched on, despite my delay. Last week, the Graham Cassidy Bill to replace the Medicaid Expansion with State Block grants fell with a thud without even being brought to a vote. This is because it did not even have enough Republican support. 

Early in the week, the Secretary of the Department of Health and Human Services resigned amidst constroversy. He was criticized for his extensive use of taxpayer funded charter flights. He was, by those in the medical community, not considered to be a friend of health care. He was viewed as a political appointee there to tow the party line. 

Most recently, Senator Bernie Sanders has revealed that this administration has been giving consideration to cutting Medicare as well as Medicaid. Medicare is the Federal Health Insurance Program for the elderly and the disabled, which Medicaid is the health insurance program for the poorest sector. Democrats allege these cuts in health care for vulnerable populations would be used to finance tax cuts “for the rich”. 

Premium prices for those purchasing health insurance through the ACA will most assuredly increase. Some increases will be more than 50%. This increase in cost of insurance premiums is NOT based on any definite information of federal subsidies reductions. Instead it is based on the THREAT of reduced or eliminated subsidy payments. Uncertainty and instability from the Federal government is causing insurers to raise prices, and is causing in insurance commissioners to allow them to do so. All premiums for all insurance plans are likely to rise. 

Prescription drug prices are likely to rise. The FDA (Food and Drug Administration) Commissioner Dr. Scott Gottleib, has declared that these high prices are a public health concern. In response, he has indicated a commitment to “more efficient generic drug development, review and approval”. 

Such uncertainty means hospitals and insurers will be unable to predict their income. This is causing them to take conservative positions across the board. This has also resulted in the closure of many rural hospitals, and the closure of maternity units within otherwise operational hospitals. More than half of all rural counties to not have a a prenatal clinic or Ob care facility. 

As discussed previously, several states have taken matters into their own hands. A red state, Utah, is fielding a proposal to expand access to birth control for low income women. Utah State Representative Ward has cited patient autonomy and cost savings as the driving benefits behind the bill. 

The morning after pill, widely considered in medical circles to be utterly safe, is now being dispensed from vending machines on certain college campuses. 

Massachusetts is considering a bill ensuring the provision of free birth control. This bill required the input of the third party payers, the insurance companies, as well as reproductive health advocates. It is expected to pass. 

In medical news, I am happy to announce the official eradication of infant and maternal tetanus. This infection once killed 10,000 newborns per year in the Western hemisphere. This has been at least in part due to the successful vaccination program using DPT in the past, and TDAP more recently. 

TDAP stands for tetanus, diphtheria, and acellular pertussis. Pertussis, also known as whooping cough, is a bad nuisance for healthy adults. However, it can be fatal in infants. All pregnant women are encouraged to get a TDAP booster in the third trimester. This turns out to confer 90% pertussis protection to the newborn. However, only half of all pregnant women got the vaccine. 

Confirmed: hormone containing IUDs do not adversely impact breastfeeding. A new study confirms what we would already expect. We expect this because hormone containing IUDs do not send hormone into the greater circulation; only to the lining of the uterus itself.  This is also the reason why they do not confer systemic side effects. 

In the bad news department, the CDC (Centers for Disease Control) report that sexually transmitted diseases are at record highs, for a second year in a row. This includes Chlamydia, gonorrhea, and syphilis. This is attributed to budget cuts impacting screening and treatment clinics but also to better testing methods. Chladmydia is soaring in women, while syphilis is most prominently increasing in gay and bisexual men. 

Much needed increased attention is being paid to post partum depression. I attended a conference today where it was highlighted that depression in this case is really a misnomer. The most common presentation of postpartum depression is anger or anxiety. A new study highlights that post partum depression is 27-47 times more likely to recur in a patient who has had it once. Postpartum depression has good treatments. More awareness and aggressive screening in the early post partum period is our best defense. 

Now we are up to date ! Stay tuned for more exciting news from the world of Obstetrics and Gynecology , here, next week, on Medical Monday.

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. 

The Year of Living Danishly: Uncovering the Secrets of the World's Happiest Country

$9.04

By Helen Russell

Buy on Amazon

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: Breaking News from the World of Obstetrircs and Gynecology

We start with encouraging policy news. Republican Kevin Brady of Texas, Chairman of the House Ways and Means Committee, has asked that Congress “ immediately provide funding for subsidies to insurance companies to keep insurance premiums affordable for subscribers in 2018. This is a provision of the current law of the land, the Affordable Care Act (ACA) . It basically means that, under the Affordable Care Act, the Federal Government pays a good chunk of the originally high insurance premiums to keep them affordable for consumers. I can appreciate Texas Representative Brady’s concerns. Health care is a huge focus in his ethnically diverse state, which is part of the so called "fat-belt", and also has the highest maternal mortality rates in the Union. Keeping his poorer constituents in health insurance costs federal tax dollars to be sure. Yet these subsidies will go to provide low priced preventive measures which will in turn prevent high priced diseases. Chairman Brady knows that beyond Texas, America, the economy and the budget cannot afford for these people to lose their health care. 

In other encouraging policy news, the board of pharmacy in New Mexico has ruled to allow pharmacists to write for oral contraceptive pills. This way, most of the time, a woman will not have to visit a physician to obtain a prescription. Physicians, especially Obstetricians and Gynecologists applaud the measure since it removes barriers to contraception, and because the safety profile of oral contraceptive pills is so good. 

Delaware has had its share of abortion restrictions, including waiting periods, parental consents, provisions that there need be maternal risk, fetal abnormalities or rape, etc, etc. However Roe vs. Wade established in the 1970s that abortion is permissible until viability, and that remains the Federal Law. Delaware recently rescinded all of of these and simply reinstated the consistency of its State Law with existing Federal law. 

Connecticut failed to pass a bill to insure, on a statewide basis, the coverage of women’s health care services through insurers operating in their state. The bill tried to ensure 21 essential benefits for women, including breast cancer screenings. The bill passed the Connecticut Senate unanimously, but died on the floor when attempts were made to amend it pursuant to abortion. Hopefully it will be edited and brought forward again, in a way that will get results. 

New York is working to safeguard coverage in their state. They have drawn up their own plan to ensure the 10 basic benefits as identical to those in the ACA, which include prescriptions, hospitalizations and maternity care. 

States handle health care for their low income populations through either the ACA or Medicaid. This was possible in part due to the Medicaid expansions that took place under the ACA. A new Kaiser Family Foundation report has shown that fully 71% of Republicans, 93% of Democrats, and 83% of Independents feel that this Medicaid expansion funding should continue. Countrywide, Medicaid covers 70 million low income children, pregnant women, disabled and elderly. I do not think, especially after seeing this data, that the American people are grudging about this expenditure of their tax dollars. They do want to know, however, that that those dollars are buying them something. There is a burden on government and the medical profession alike to demonstrate with data how Medicaid dollars spent on routine care save huge monetary and societal costs later. In the field of Obstetrics and Gynecology, this sort of research has been done. For example, it has been shown that birth control is the best value on the dollar anywhere. 

Medical Monday will conclude there for tonight, at the end of our policy section. Tomorrow I will tackle the medical news, as tonight has gotten rather short. 

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

Forty prominent groups concerned with women’s health have written a letter of complaint to the new administration. The recipients include President Trump, the Secretary of the Department of Health and Human Services Tom Price, White House aide Ivanka Trump. The letter has criticized each of the major changes that the present administration has either enacted or proposed, for example replacing Obamacare, cutting funds to Medicaid, reducing access to women's healthcare by shutting down Planned Parenthood as well as the "global gag rule”, also known as the “ Mexico City policy”  which prevents international organizations who offer abortion as part of their services from receiving any US funds. The letter further alleges that women's healthcare needs have been traded for political benefit. The letter went out during Women's Health Week to call attention to the issues. In order to begin addressing these concerns, Ivanka Trump has begun meeting with various groups concerned with women’s health, including female Democratic leaders. 

Imposition of the global gag rule may cut off millions in funding to combat other conditions like HIV/AIDS and malaria, leading to a global health crisis. 

In a move long opposed by Republicans, the Trump administration’s budget proposal will include 6 weeks of paid family leave for both mothers and fathers. 

Texas is still trying deal with having shot itself in the foot. Texas took a stand against abortion and removed Planned Parenthood from their Federal Funding recipients. By doing so under the Obama administration, they lost their Federal funding for the Texas Medicaid Women’s Health Program. Texas has the highest maternal mortality rate of all the States, and a very high percentage of uninsured people. They want their Federal funds back. 

Health insurance is not just about a single subscriber, or even a single family. It is a funding pool that we agree to make together, that lets us all have predictable manageable health expenses, even if something really bad and expensive should happen. It also is a way for everyone in society to help safeguard the future, by contributing to the care of the next generation. This is done by contributing to a pool that pays for the care of women and children. This elementary and beneficial concept behind health insurance seems to have escaped Republican Rod Blum from Iowa who believes men do not need to contribute to an insurance pool which covers pregnancy. He was jeered off the stage in a town hall meeting. 

And now for a piece of news that cinches the connection between policy and health care. Research presented at the annual meeting of ACOG (The American College of Obstetricians and Gynecologists) has shown that the Affordable Care Act (ACA) under Obama led many pregnant women to get prenatal care earlier and that led to better perinatal outcomes. Of course this is in jeopardy now. 

Researchers with the American Cancer Society have presenting new findings indicating that increased access to care under the ACA led to early detection of some cancers. These included breast, colon and lung cancers. Early diagnosis leads to more cures and longer survival. The biggest changes occurred in states with significant Medicaid expansions. These gains too are in jeopardy. 

A recent study has shown that women under fifty doubled their survival time in recent years. I suspect mammograms played a role in this. There is controversy on when mammograms should start: 40 versus 50. ACOG recommends 40. So do breast cancer survivors under 50. Cancer patients over 50 also saw increased survivals, but not quite so dramatic. 

The World Heath Organization has presented the shocking news that pregnancy complications are the leading cause of death for teenage girls worldwide. The biggest causes were hemorrhage, complications  from abortion, and obstructed labor. 

Lancet, one of the world’s premier medical journals produced research on “ Amenable Mortality”. “Amenable Mortality means deaths that could’ve been avoided through timely or effective medical care. American scores 80 on the heal care quality index (HAQ) and that is at the bottom on the second decile, on a par with Estonia and Montenegro. 

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.