Beyond Obamacare

A very strong argument in favor of Anabolic Medicine ^sm.

From the New York Times

September 16, 2012

Beyond Obamacare

By STEVEN RATTNER

WE need death panels.

Well, maybe not death panels, exactly, but unless we start allocating health care resources more prudently — rationing, by its proper name — the exploding cost of Medicare will swamp the federal budget.

But in the pantheon of toxic issues — the famous “third rails” of American politics — none stands taller than overtly acknowledging that elderly Americans are not entitled to every conceivable medical procedure or pharmaceutical.

Most notably, President Obama’s estimable Affordable Care Act regrettably includes severe restrictions on any reduction in Medicare services or increase in fees to beneficiaries. In 2009, Sarah Palin’s rant about death panels even forced elimination from the bill of a provision to offer end-of-life consultations.

Now, three years on, the Republican vice-presidential nominee, Paul D. Ryan, has offered his latest ambitious plan for addressing the Medicare problem. But like Mr. Obama’s, it holds limited promise for containing the program’s escalating costs within sensible boundaries.

The Obama and Ryan plans are not without common ground; both propose an identical formula for capping the growth in Medicare spending per beneficiary. And both dip into the same toolbox (particularly lower payments to providers) to achieve a reduction of nearly $1 trillion in Medicare expenditures over the next decade from projected levels.

That’s where the agreement ends. Mr. Ryan believes that meeting the goal over the long term requires introducing more competition into Medicare through vouchers to purchase private insurance.

But Ryan’s approach was rendered toothless when the issue’s brutal politics forced him to retreat from his initial tough plan to simply cap the growth in government spending on Medicare and stick the inevitable overage onto beneficiaries. Under his revised plan, private insurers would be required to offer the same level of benefits as traditional Medicare, meaning that any savings would have to come from unidentified efficiencies (the ever-popular “waste, fraud and abuse”).

If the cap was breached — as it almost certainly would eventually be — Mr. Ryan blithely says, “Congress would be required to intervene.” Fat chance; Congress regularly does the opposite when it rolls back caps on payments to doctors and hospitals.

Meanwhile, Mr. Obama’s hopes for sustained cost containment are pinned on a to-be-determined mix of squeezing reimbursements, embracing a selection of the creative ideas that have spewed forth from health care policy wonks and scouring the globe for innovations.

To Mr. Obama’s credit, his plan has more teeth than Mr. Ryan’s; if his Independent Payment Advisory Board comes up with savings, Congress must accept either them or vote for an equivalent package. The problem is, the advisory board can’t propose reducing benefits (a k a rationing) or raising fees (another form of rationing), without which the spending target looms impossibly large.

That’s the view of the bipartisan Medicare trustees, whose 2012 report stated: “Actual future Medicare expenditures are likely to exceed the intermediate projections shown in this report, possibly by quite large amounts.”

To be sure, health care cost increases have moderated, in part because of the recession and in part because Medicare has been tightening its reimbursements. But those thumbscrews can’t be tightened forever; Medicare reimbursement rates are already well below those of private providers.

Let’s not forget that with the elderly population growing rapidly, even if cost increases for each beneficiary can be contained, Medicare would still claim a rising share of the American economy.

Medicare needs to take a cue from Willie Sutton, who reportedly said he robbed banks because that’s where the money was. The big money in Medicare is not to be found in Mr. Ryan’s competition or Mr. Obama’s innovation, but in reducing the cost of treating people in the last year of life, which consumes more than a quarter of the program’s budget.

No one wants to lose an aging parent. And with price out of the equation, it’s natural for patients and their families to try every treatment, regardless of expense or efficacy. But that imposes an enormous societal cost that few other nations have been willing to bear. Many countries whose health care systems are regularly extolled — including Canada, Australia and New Zealand — have systems for rationing care.

Take Britain, which provides universal coverage with spending at proportionately almost half of American levels. Its National Institute for Health and Clinical Excellence uses a complex quality-adjusted life year system to put an explicit value (up to about $48,000 per year) on a treatment’s ability to extend life.

At the least, the Independent Payment Advisory Board should be allowed to offer changes in services and costs. We may shrink from such stomach-wrenching choices, but they are inescapable.

Steven Rattner, a contributing opinion writer, was a counselor to the Treasury secretary in the Obama administration.

Nandrolone normalizes determinants of muscle mass and fiber type after spinal cord injury.

Prevalence and risk factors of diabetes in patients with Klinefelter syndrome: a longitudinal observational study.

Analysis of muscle strength and body composition of women with Polycystic Ovary Syndrome.

Twenty-five milligrams of clomiphene citrate presents positive effect on treatment of male testosterone deficiency - a prospective study.

Therapeutic Testosterone Administration Preserves Excitatory Synaptic Transmission in the Hippocampus during Autoimmune Demyelinating Disease.

Testosterone replacement therapy among elderly males: the Testim Registry in the US (TRiUS).

With Medicaid, Long-Term Care of Elderly Looms as a Rising Cost

Medicaid has long conjured up images of inner-city clinics jammed with poor families. Its far less-visible role is as the only safety net for millions of middle-class people whose needs for long-term care, at home or in a nursing home, outlast their resources.

With baby boomers and their parents living longer than ever, few families can count on their own money to go the distance. So while Medicare has drawn more attention in the election campaign, seniors and their families may have even more at stake in the future of Medicaid changes — those proposed, and others already under way.

Though former President Bill Clinton overstated in his convention speech on Wednesday how much Medicaid spends on the elderly in nursing homes — they account for well under a third, not nearly two-thirds, of spending — Medicaid spends more than five times as much on each senior in long-term care as it does on each poor child, and even more per person on the disabled in long-term care.

Seniors like Rena Lull, 92, who spent the last of her life savings on $250-a-day nursing home care near Cooperstown, N.Y., last year, will face uncharted territory if Republicans carry out their plan to replace Medicaid with block grants that cut spending by a third over a decade. The move would let states change minimum eligibility, standards of care, and federal rules that now protect adult children from being billed for their parents’ Medicaid care.

Now, like a vast majority of the nation’s 1.8 million nursing home residents, Mrs. Lull, a retired schoolteacher with dementia, counts on Medicaid to cover most of her bill. But her daughter Rena, 66, also a retired schoolteacher with a lifetime of savings, no longer knows what she can count on in her own old age.

“I get choked up thinking about this,” she said, recalling how her widowed mother had depleted $300,000 on five years of care in the community and one year in the Otsego Manor nursing home, before qualifying for Medicaid. “I’m so scared about what’s going to happen to me.”

The presidential election may decide Medicaid’s future. But many states faced with rising Medicaid costs and budget deficits are already trying to cut the cost of long-term care by profoundly changing Medicaid coverage, through the use of federal waivers.

Waivers sought or obtained by 26 states, including New York, California, Illinois and Texas, would affect some three million people, most of them eligible for both Medicaid and Medicare. Plans vary, but typically they try to cut costs by giving private managed-care organizations a fixed sum for a lifetime of care, from doctor and hospital visits to help at home to nursing home placement, with the expectation that more care will take place in less expensive home or community settings.

Over all, 31.5 percent of Medicaid’s $400 billion in shared federal and state spending goes to long-term care for the elderly and the disabled. That ranges from less than 8 percent in Hawaii, where nursing home use is low, to more than 60 percent in North Dakota...

The Benefits of Middle-Age Fitness

Americans are living longer, with our average life expectancy now surpassing 78 years, up from less than 74 years in 1980. But we are not necessarily living better. The incidence of a variety of chronic diseases, like diabetes, cancer and heart disease, has also been growing dramatically, particularly among people who are not yet elderly.

The convergence of those two developments has led to what some researchers have identified as a “lengthening of morbidity.” That means we are spending more years living with chronic disease and ill health — not the outcome that most of us would hope for from a prolonged life span.

But a notable new study published last week in Archives of Internal Medicine suggests that a little advance planning could change that prospect. Being or becoming fit in middle age, the study found, even if you haven’t previously bothered with exercise, appears to reshape the landscape of aging...

Development of hepatocellular carcinoma associated with anabolic androgenic steroid abuse in a young bodybuilder: a case report.

Introduction. Many different etiological factors are involved in the development of hepatocellular carcinoma (HCC). We report the case of HCC in a 37-year-old male professional bodybuilder with extensive anabolic androgenic (AAS) steroid abuse. Case Presentation. Because of increasing epigastric and abdominal pain, abdominal ultrasound was performed in a 37-year-old male professional bodybuilder. A hyperechoic lesion in the liver was detected in segment VI. The magnetic resonance imaging showed hepatomegaly and confirmed the lesion, which showed features of a hepatocellular adenoma (HCA). Laboratory values were inconspicuous. After laparoscopic segmentectomy the histological examination revealed HCC. Conclusion. While the development of HCA in the liver by chronic intake of AAS is well known, little is known about the association with HCC. The presented case may indicate aetiological association of chronic intake of AAS and the development of HCC.

Age-related changes of skeletal muscles: physiology, pathology and regeneration.

This review provides a short presentation of the aging-related changes of human skeletal muscles. The aging process is associated with the loss of skeletal muscle mass (sarcopenia) and strength. This results from fibre atrophy and apoptosis, decreased regeneration capacity, mitochondrial dysfunction, gradual reduction of the number of spinal cord motor neurons, and local and systemic metabolic and hormonal alterations. The latter involve age-related decrease of the expression and activity of some mitochondrial and cytoplasmic enzymes, triacylglycerols and lipofuscin accumulation inside muscle fibres, increased proteolytic activity, insulin resistance and decreased serum growth hormone and IGF-1 concentrations. Aging of the skeletal muscles is also associated with a decreased number of satellite cells and their proliferative activity. The age-related reduction of skeletal muscle mass and function may be partially prevented by dietary restriction and systematic physical exercises.

Determinants of Bone Microarchitecture and Mechanical Properties in Obese Men.

Context:Recent studies have suggested that obesity in men is associated with increased fracture risk. Obesity in men is also associated with dysregulation of the GH/IGF-I and gonadal steroid axes, important regulators of bone homeostasis.Objective:The aim of the study was to investigate body composition and endocrine determinants of bone microarchitecture and mechanical properties in obese men.Design and Setting:We conducted a cross-sectional study at a clinical research center.Participants:Thirty-five obese men (mean age, 33.8 ± 6.4 yr; mean body mass index, 36.5 ± 5.8 kg/m(2)) participated in the study.Outcome Measures:Distal radius microarchitecture and mechanical properties were measured by three-dimensional high-resolution peripheral quantitative computed tomography and microfinite element analysis; body composition by computed tomography; bone marrow fat by proton magnetic resonance spectroscopy; total and free estradiol and testosterone; IGF-I; peak glucagon-stimulated GH; 25-hydroxyvitamin D.Results:Men with high visceral adipose tissue (VAT) had impaired mechanical properties compared to men with low VAT (P < 0.05), despite comparable body mass index. VAT was inversely associated and thigh muscle was positively associated with mechanical properties (P < 0.05). Bone marrow fat was inversely associated with cortical parameters (P ≤ 0.02). Free estradiol was positively associated with total density (P = 0.05). Free testosterone was positively associated with trabecular thickness and inversely with trabecular number (P ≤ 0.05). Peak stimulated GH was positively associated with trabecular thickness, as was IGF-I with cortical area (P ≤ 0.04).Conclusion:VAT and bone marrow fat are negative predictors and muscle mass is a positive predictor of microarchitecture and mechanical properties in obese men. Testosterone, estradiol, and GH are positive determinants of trabecular microarchitecture, and IGF-I is a positive determinant of cortical microarchitecture. This supports the notion that VAT is detrimental to bone and that decreased GH and testosterone, characteristic of male obesity, may exert deleterious effects on microarchitecture, whereas higher estradiol may be protective.