Issue: 66

July: A Tipping Point in the Healthcare Debate!
Opposition to Obamacare has all but evaporated, perhaps the most striking public opinion turn-around in recent memory. Some columnists say, "It's hard to refuse a hand-out" but their cynicism belies the fact that most of those polled receive no direct benefit from Obamacare. Indeed, they are paying for it! So, the real question is why those who are financially disadvantaged by Obamacare are suddenly opposing its repeal.
Here are some plausible explanations. First, the Republicans can no longer characterize Medicaid expansion as "welfare" because most of the households have at least one working member, especially as unemployment declines. Thus, the notion that states could/should require Medicaid expansion recipients to work has failed to gain traction. Most already do. Second, unlike other federally funded/state administered programs such as Food Stamps (SNAP: Supplemental Nutrition Assistance Program) where it is facile to parse the populace into "us and them," Obamacare beneficiaries are much closer to "us." Not only do recipients work, they install our replacement windows, remodel our kitchens, operate road-side stands, replace our leaky hot water heaters and, in general, work for firms and businesses that are too small to be covered by the employer mandate. The line between "us and them" has thus been blurred for the better. Many of us are reminded of growing up in working households where money was tight. There was no meat on Friday but there was no money to buy meat anyway. Third, those who obtain their insurance through the exchanges have "skin in the game" because their subsidy is inversely proportional to their income. Those who bristled at the individual mandate now see it more like a Pell Grant, a hugely successful needs-based subsidy program that has allowed millions to obtain a college education with federal dollars.
John A. Schmidt, MD 
To be sure, there are huge problems to be addressed if Obamacare and Medicaid expansion are to survive. The deductibles and copayments are rising and the insurance/provider networks are shrinking. A conservative at heart, I believe there is nothing wrong with insisting beneficiaries take an active role in their own health care and thereby keep a lid on ballooning costs. Motorists who drink and drive, fail to wear their seat belts, speed, text while driving, etc. are high-risk and deserve to pay higher auto-insurance premiums, enter a high-risk pool, or have their insurance suspended. Similarly, those who endanger their health by smoking, overeating, under-exercising, and flush their prescription medicines down the toilet deserve to pay risk-stratified premiums or lose their coverage. The costs to society of the opioid epidemic pale in comparison to the mountain of debt from the obesity epidemic, Governor Christie! (see below). " Pre-existing conditions" covers a multitude of ills, some of which are self-inflicted. In a "zero sum game" with so many deserving and competing priorities, we have to be wise, prudent, and just.
Obesity Pandemic
Charles Dickens was among the first authors to describe the ill effects of obesity when he described the "elastic fixtures" of the "fat boy" in the Pickwick Papers. The obese fat boy had sleep apnea and fell asleep at the drop of a hat leading medical historians to coin the " Pickwickian Syndrome."
As reported in the New England Journal of Medicine on July 6, "The prevalence of obesity ( BMI> 30) among children and adults has doubled in 73 countries since 1980 and has shown a continuous increase in most other countries. In 2015, the highest level of childhood obesity was observed in the United States (12.7%). In 2015, China and India had the highest numbers of obese children, whereas the United States and China had the highest numbers of obese adults." More than 90% of deaths attributable to BMI (mainly cardiovascular disease with lesser contributions from diabetes, chronic kidney disease, and a variety of cancers) occurred among individuals with BMI's greater than 25. "The lowest overall risk of death was observed for a BMI of 20-25."
The authors say, "...the problem is not simply a function of income or wealth. Changes in the food environment and food systems are probably major drivers. Increased availability, accessibility, and affordability of energy-dense foods, along with intense marketing of such foods, could explain excess energy intake and weight gain among different populations."
Read the article in the July 22 New York Times discussing how the new head of the CDC, Dr. Brenda Fitzgerald, attempted and failed to enlist Coca-Cola in the war against childhood obesity. Coca-Cola responded with a campaign emphasizing exercise, completely ignoring the role sugary drinks play in promoting childhood obesity. Even Warren Buffett, who is often lauded for his philanthropy, has recently defended his investment in Coke-grrr!!! It's paradoxical that the study in the New England Journal of Medicine was funded by the Gates Foundation, whose founder Buffett claims to hold in high esteem! Actions, not words, are what is needed, Mr. Buffett!
Modern medicines have softened the blow of obesity on public health. "Clinical interventions have proven to be effective in controlling high levels of systolic blood pressure, cholesterol , and fasting blood glucose, the major risk factors for cardiovascular disease."
But before you sigh relief: "...this success leads to more years of disabling, non-fatal, illness." We are left with a pudgy, disabled population with higher systolic blood pressure, higher cholesterol, and higher fasting blood glucose requiring more medicine, more trips to the doctor, more ER visits, more time lost from work, more interventions, and soaring health care costs!
Who is to blame? The often vilified pharmaceutical companies who make the medicines to combat the ill effects of obesity, the food and beverage companies who expand our waistlines, or our undisciplined selves? This much is clear: Targeting couch potatoes with fast food ads juxtaposed with Direct-to-Consumer ads for Jardiance® and Trulicity®, is perverse and increases the future burden on Medicaid, Medicare, and Social Security thereby posing an existential threat to the health and financial security of our nation!
Therapeutic Advances
This month saw several therapeutic advances. Here are two important examples:
As published online on July 11 in the New England Journal of Medicine, an antibody fragment (idaricuzumab ®) rapidly and safely reversed Dabigatran ( Pradaxa®) in patients with bleeding or in need of emergency surgery. Pradaxa® is the only one of the modern anticoagulants ( Pradaxa®, Xarelto®, Eliquis®) to have a potent, specific antagonist. Warfarin is reversible with vitamin K but the reversal is slow and unpredictable. This gives Pradaxa ® a clear advantage over the other agents.
As published online on July 10 in the New England Journal of Medicine, a bispecific antibody (emicizumab®) prevented bleeding in patients with hemophilia A who had developed inhibitors to factor VIII concentrate. As the editorialist wrote, "These are extraordinary times for innovation in hemophilia therapy, and the introduction of emicizumab® represents a major contribution toward achieving an enhanced standard of care for this lifelong bleeding disorder."
Coffee Drinking and Mortality
As published in the July 11 issue of the Annals of Internal Medicine, "Coffee drinking was associated with reduced risk for death from various causes." Conclusion: Moderate coffee intake can be part of a healthy diet.
The Deadly Consequences of Stopping Statins
As published in the July 25 issue of the Annals of Internal Medicine in an editorial by Stephen Nissen MD, "Statins (atorvastatin, rosuvastatin, etc.) have developed a bad reputation with the public, a phenomenon driven largely by proliferation on the Internet of bizarre and unscientific ... criticism of these drugs. For those stopping statins, the risk of cardiovascular disease increases 1.22 to 5.26 times and the risk of death increases 1.25 to 2.54 times (De Vera, et al. British J of Clin Parmacol, 2014.)" Statins save lives and prevent disability due to heart attack and stroke. Stopping statins is perilous!

Patient Portal Please!!
To encourage you to try the  Follow My Health Patient Portal, we decided to offer an incentive. Everyone that communicates with me during the month via email on our secure portal will be placed into a drawing for a $50 AMEX gift certificate. One lucky patient will win the gift certificate each month. I hope this will encourage you to give the Patient Portal a try. Not only will you save time when you need to make an appointment, request a prescription refill, ask me a question, or review your lab results, but you can enjoy dinner on me!

As discussed in previous newsletters, the patient portal is one of the most efficient ways to keep in touch with us and manage your health care. The portal gives you access to your personal health information (PHI), including LabCorp results, and it also allows you to communicate with me using encrypted, HIPAA compliant, email. You will get faster answers and notifications of your lab results. 

If you do not already have a portal account, kindly ask Valerie to send you an invitation today!!!
Now Hear This!
Tick season is in full swing! Wear insect repellant, cover up, and inspect your skin and scalp for evidence of ticks. Remove ticks promptly and call me if you see any evidence of a rash.
Valerie, Morgan, Ms. Clark, and I wish you a restful and safe summer full of memories to be cherished for a lifetime!
In This Issue
July: A Tipping Point in the Healthcare Debate
Obesity Pandemic
Therapeutic Advances
Coffee Drinking and Mortality
The Deadly Consequences of Stopping Statins
Patient Portal Please!!
Now Hear This!
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering  Medical Home  services.  
He is an attending physician at Jersey Shore University Medical Center.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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"No one is useless in this world who lightens the burdens of another." 
- Charles Dickens


Dr. Schmidt's New Office in Spring Lake Heights
John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
2006 Highway 71, Ste. 3, Spring Lake Heights, NJ 07762
Phone:  732-282-8166  
Fax:  732-280-0147 
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.