the city you live in might determine your health insurance status

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The US Census Bureau released figures this week of the uninsured rate in America’s major metropolitan areas.

Seven of the largest metro areas where the uninsured rate was higher than the 14.5% percent national average are located in states that refused to expand Medicaid – 2 in Florida, 3 in Texas, and 1 in Georgia and North Carolina each. The metro area with the highest uninsured rate was Miami, at a staggering 25%, compared to the national low of 4% in greater Boston.

cities people with health insurance

Preventing cancer

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When we were growing up, our mothers often told us that we are what we eat.  Well, it turns out that some of us are apparently eating cancer.

The Atlantic made my job incredibly easy when they posted an article yesterday about America’s poor health habits and the association with cancer.  The article cites the American Association for Cancer Research’s new cancer progress report, which noted that roughly 50% of the 585,720 projected cancer deaths in the United States this year are related to preventable behaviors, with smoking being the biggest culprit.  But poor diet and sedentary lifestyles accounted for nearly one third of preventable cancer deaths.

The good news?  Smoking rates in the United States continue to decline, and smoking related cancers also seem to be on the decline.  Obesity rates, however, continue to climb in the US – and their associated cancers are also increasing.  Not to mention that smoking and obesity are synergistic – in combination, the two habits increase the risk for cancer.

cancer personal habits diet exercise smoking

overread

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According to domestic violence experts, more than three women a day lose their lives at the hands of their partners.  That means that since the night of February 15th in Atlantic City, more than 600 women have died.  So this is yet another call to men to stand up and take responsibility for their thoughts, their words, their deeds and to get help…. because our silence is deafening and deadly.

~James Brown

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Tradition per se has no positive or negative significance.  There are good traditions, bad traditions pilloried in such famous literary stories as Franz Kafka’s In the Penal Colony and Shirley Jackson’s The Lottery, bad traditions that are historical realities such as cannibalism, foot-binding, and suttee, and traditions that from a public-policy standpoint are neither good nor bad (such as trick-or-treating on Halloween).  Tradition per se therefore cannot be a lawful ground for discrimination – regardless of the age of the tradition.

Wisconsin points out that many venerable customs appear to rest on nothing more than tradition – one might even say on mindless tradition.  Why do men wear ties?  Why do people shake hands (thus spreading germs) or give a peck on the cheek (ditto) when greeting a friend?  Why does the President at Thanksgiving spare a brace of turkeys (two out of the more than 40 million turkeys killed for Thanksgiving dinners) from the butcher’s knife?  But these traditions, while to the fastidious may seem silly, are at least harmless.  If no social benefit is conferred by a tradition and it is written into law and it discriminates against a number of people and does them harm beyond just offending them, it is not just a harmless anachronism; it is a violation of the equal protection clause…

- Judge Richard Posner, U.S. Seventh Circuit Court of Appeals in the panels unanimous decision striking down the appeal of Indiana and Wisconsin same-sex marriage bans

What killed Joan Rivers?

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This morning, CNN published a story surrounding the death of the hilarious Joan Rivers, who died at New York’s Mount Sinai Hospital on Thursday after undergoing elective throat surgery at Yorkville Endoscopy.  Joan Rivers was laid to rest today with a star-studded funeral in New York City.

Though I have my own thoughts on the subject, we may never know what exactly led to Joan’s ultimate and unfortunate demise, as the medical examiner’s autopsy was “inconclusive”.  But beyond the loss of a powerful and history making female celebrity, Joan’s death brings up two incredibly important points to me as a health care provider.

The first is that we as physicians, particularly those of us who perform procedures, have become the victims of our own success to a certain extent.  We often remark that patients are undergoing a “routine” or “elective” procedure – I have often remarked that a patient is “just having a hernia repair”.  But as the CNN article points out, calling a surgery “routine” or “elective” doesn’t mean it is simple or risk-free.  Every procedure we do has risks, whether planned in advance (elective) or emergency surgery.  Even the most mundane procedures carry risks.

A good friend of mine who also happens to be a resident physician posted the following on Facebook, and I couldn’t agree more.  As a nation and as a medical profession, we’ve collectively done a terrible job at discussing end of life decisions and goals of care.  Melissa Rivers should be commended for following her mother’s wishes.

Since every recent national tragedy results in us needing to have a national conversation (on guns, mental health, race), can we please take Joan Rivers’ death and have a national conversation on goals of care?

Many of us residents have dealt with hundreds of situations like Joan, and from what the news says (I was not involved in any way in Joan’s care), Joan lost her pulse, and CPR/ACLS kept her alive, but she never regained her mental status. Her goals were pretty clear, as she said them on national TV: if she couldn’t be functional (doing stand-up comedy, using her brain), she didn’t want to be kept alive. And it seems her daughter Melissa respected what Joan wanted, didn’t fight to keep her alive – trach’d and peg’d and living in a nursing home for months or longer in a chronically critically ill state with decubitus ulcers and line infections just because she couldn’t let go. They decided to no longer keep Joan’s body alive with life support, as it’s what Joan had said she wanted.

So please, talk to your parents and grandparents about what they want in case of tragedy. Have clear goals. Respect what your family would have wanted. Make a reasonable decision. *gets off soapbox*

 

Kudos to you, CVS… HEALTH

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In February, CVS made an unprecedented announcement – all of its 7600+ retail locations would stop selling cigarettes and other tobacco products.  The company became the first pharmacy chain to ban the sale of tobacco products, claiming that the continuing to sell cigarettes wasn’t consistent with the company’s increasing focus on its customers’ health.  “Focusing on its customers’ health” will cost CVS roughly $2 billion in revenue, a mere fraction of its overall revenue.

Yesterday, CVS announced that it was removing cigarettes from its shelves one month earlier than previously reported and simultaneously launched a smoking-cessation program for customers.  In the announcement, the corporate entity opted for a name change – to CVS Health.

So why the shift?  Simple – health care is a more lucrative market than retail, and CVS wants to be seen as a legitimate health care company.  It’s a no brainer really – tobacco sales accounted for less than 2% of CVS total revenue and tobacco sales overall are declining.  Additionally, tobacco sales are a fairly low-margin product, meaning tobacco probably accounted for even less of the company’s profits.

Health care on the other hand?  The company already runs 900 Minute Clinics, and pharmacy services already account for more than half of CVS’s annual revenue.  It’s a lot easier to market yourself as a health care company when you don’t have cigarettes behind the counter.

Snaps to CVS.

CVS quits for good ends tobacco sales

there had to be one…

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Yesterday, a federal judge in Louisiana ruled that the state’s ban on same-sex marriage is constitutional.  The ruling from U.S. District Judge Martin Feldman in Louisiana is the first ruling in over a year to uphold a ban on same-sex marriage, and therefore to uphold discrimination.  Judge Feldman’s court is also the only federal court to uphold a marriage ban since the U.S. Supreme Court ruled on the Defense of Marriage Act last year.

In his ruling, Judge Feldman wrote, “The Court is persuaded that a meaning of what is marriage that has endured in history for thousands of years, and prevails in a majority of states today, is not universally irrational on the constitutional grid.”

While Judge Feldman’s ruling is certainly an upsetting setback for the LGBT community, particularly in Louisiana, the ruling underscores the necessity of a definitive Supreme Court ruling.  Hopefully Judge Feldman will be the lone dissenting voice in history and quickly find himself on the wrong side of history.

the Medicaid expansion gap

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Last week, Pennsylvania Governor Tom Corbett announced that the state had worked out an alternative Medicaid expansion plan with the federal government, bringing 500,000 low-income Pennsylvanians to the Medicaid rolls.

According to numbers from the Kaiser Family Foundation, about 281,000 of those people were falling into what’s known as the “coverage gap.” All state Medicaid programs generally cover some low-income adult populations with certain stipulations – for example, those with disabilities or single mothers.  Under the original terms of the Affordable Care Act, states would “expand Medicaid eligibility” to all low-income adults earning up to 133% of the federal poverty level (roughly $15,500).   In the wake of the Supreme Court’s ruling on the ACA, states no longer were obligated to expand Medicaid eligibility.  These people fall in the gap, they don’t qualify for a non-expanded Medicaid but also don’t get subsidies for purchasing insurance on their own since they don’t make more than the federal poverty level either. According to the Kaiser Family Foundation, about 4.5 million people across the country fall into this coverage gap.

Currently, 23 states aren’t expanding Medicaid – but there are rumblings that a few more may follow in Pennsylvania’s footsteps.

Medicaid coverage gap