The Basics of Medicare

Since we are in the Medicare “open enrollment” period, Oct 15-Dec 7, now is a good time for a quick review.

Medicare was enacted in 1965. It established parts A and B. Part A is free to all Americans 65 and older and to younger people with chronic kidney disease or who are chronically disabled. It pays 80% of hospital bills after a deductible. Part B, for which you pay, covers doctor fees and most outpatient services. Part B also has a deductible and covers 80% of the charges.

While Medicare B is voluntary, it would be playing Russian roulette to not take it, as you would have no coverage for doctor bills. Most people pay $185/month for Medicare Part B, though this goes up for those with higher incomes. It also goes up if you delay enrolling.

Medicare Part D became available in 2006. It is optional and helps pay for prescriptions. You must sign up and choose a plan annually. Typical premiums run about $50/month.

Because A and B only cover 80% of your medical bills, and these bills can mount up dramatically if you have a serious illness, most people pay for a supplemental policy to cover the 20%. These so-called “medigap” plans are offered by private insurers, not the government.

Part C, establishing what is now called Medicare Advantage, began in 1997. It gives private insurance companies a fixed amount per person per year to cover their medical expenses. The theory was that private health insurers would provide equal or better care and save the government money, a theory that has been proven wrong.

Medicare Advantage plans advertise heavily, and promise lower costs and extra benefits. At this time of year, you will be inundated with direct mail, phone calls and media blitzes trying to entice you to join an Advantage plan.

If you join such a plan, you must still pay your Part B premium, but typically will not have to pay for a medigap plan or Part D. Your monthly insurance premiums will usually thus be lower. There is, however, no free lunch. Under traditional Medicare A and B, you can be treated by almost every doctor and hospital in the country. This is not true for Advantage plans.

In return for the lower insurance cost, you will be restricted in the doctors and hospitals you can use and you will find that your doctors’ recommendations are subject to the whims of the insurance companies. Most hospital care and any expensive test or medication will only be covered if the insurance company approves it. I do not have space here to cover all the issues, and strongly recommend you Google “John Oliver Medicare Advantage” (the 31 minute one) for a biting and humorous look at the problem.

People who sign up for Medicare Advantage when they are healthy can be fine if they stay healthy. If they develop a serious illness they may regret their choice, as they find that the doctors and hospitals they would like to use for their care are not available.

Switching back to traditional Medicare would seem like an option, but there is a catch. When you first go on Medicare, you have free choice of medigap plans. They cannot refuse you because you are in poor health. If you try to sign up for one of these plans later, they can refuse to cover you at all or refuse to pay for pre-existing conditions. Just when you would need that 20% covered, it will not be, so you are locked into your Advantage plan.

My strong advice is that if you can afford the extra cost, start and stay with traditional Medicare and a good medigap plan. Otherwise, if you choose an Advantage plan, stay healthy!


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Time to say goodbye to Benadryl?

Diphenhydramine, commonly known by the brand name Benadryl, has been sold since 1946. It is an “antihistamine,” meaning it blocks the body’s receptors for the chemical histamine, which is released in response to allergens.

Diphenhydramine works very well to lessen allergy symptoms and is used not only as the sole ingredient in Benadryl but as all or part of the makeup of some 300 mostly over-the-counter medicines.

Diphenhydramine crosses into the brain and makes us drowsy. This “side effect” has caused it to become a widely used sleeping aid. Most OTC sleep aids have diphenhydramine (or doxylamine, a very similar product) as their active ingredient.

The problem with using these older antihistamines for allergy relief is that they are sedating and may make users too drowsy to safely drive or do other tasks requiring attention. They can be especially problematic for older adults and have been linked to falls and auto accidents. Regular use has also been linked to risk of dementia.

They can also be a problem with small children, causing extreme sedation and even coma. Also, oddly enough, in some children they have a paradoxical effect of causing agitation.

For allergy relief three newer antihistamines are available: loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra). These do not get into the brain and are much less likely to be sedating.

How about for sleep?

For very occasional use, diphenhydramine and other older antihistamines are probably OK. Like most sleeping pills, the sleep induced by antihistamines is not natural, with little REM sleep, and the sedation can linger well into the next day. It is not dissimilar to the sleep you get after drinking too much alcohol.

Better choices are melatonin or chamomile, which work immediately, or magnesium, which must be taken regularly and build up in your system. If you find yourself using an antihistamine to sleep more than 2-3 times a month, ask your doctor about alternatives.

So, yes, it is probably time to say adios to diphenhydramine, doxylamine and all the older antihistamines. Be sure to read the labels on OTC products before you buy them.


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Public Health is Not a Partisan Issue

This fall has seen a major outbreak of listeria, a bacterium that can spread via many foods, sickening people in 15 states, with at least 19 hospitalized and four deaths. The outbreak has been tied to packaged pasta meals made by Fresh Realm.

How did we know this and so were able to recall products sold by Fresh Realm? We knew it because of the Foodborne Diseases Active Surveillance Network, commonly called FoodNet. This highly successful program monitors labs in 10 states around the country and actively investigates possible food-borne illnesses.

Despite its critical role in protecting Americans from food-borne illness, the program was drastically curtailed recently. While not closed, staffing was cut and henceforth only two of the prior eight pathogens will be monitored – listeria one of the six cut, along with campylobacter, even though these two bacteria made thousands sick and killed 72 people in 2022.

More recently, draconian cuts were made to the staff of the Communicable Disease Center (CDC), supposedly due to the government shut-down and President Trump’s goal of destroying “Democrat programs.” [Note that about half the staff fired on Friday were reinstated over the weekend!]

When I need to know about the description of a tropical disease that may have been imported to the U.S. or want to follow disease outbreaks anywhere in the world, the first place I look is the CDC-published MMWR (Morbidity and Mortality Weekly Reports). This publication is usually the first to report on new and emerging infectious diseases.

No longer, I guess, as virtually the entire staff of MMWR were fired last Friday.

Despite RFK Jr’s insistence that his top priority was the burden of chronic disease in America, most of the staff guiding our response to chronic disease was also fired, along with those monitoring and responding to the opioid crisis.

The Director of the CDC was fired last month because she refused to be a rubber stamp for ideologues and said she would rely on science rather than politics in her decision-making.

I have met many CDC employees over the years. They are dedicated professionals who could generally be earning more in the private sector but believe in the life-saving mission of the CDC.

We cannot sit idly by while the agencies that keep us healthy are gutted. Write to the White House. Write to your senators and representative. Public health protects Republicans, Democrats and independents. It must not be allowed to fall victim to partisan politics.


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Is acetaminophen harmful in pregnancy?

The short answer to that question is: probably not but we cannot be absolutely certain.

Let me beg your indulgence in an explanation about why that is the only honest answer I can give you.

The “gold standard” in assessing the risks and benefits of any medication is the “controlled trial”. In such a trial, a large group of people are randomly assigned to drug A or drug B or to Drug A or placebo. This tends to ensure that differences in outcomes between the people taking one treatment or the other are due to the treatment and not to the characteristics of the people taking them. With a large enough group and truly random assignment, differences among the subjects are assumed to be evenly spread.

Historically, drug trials have excluded pregnant women because the trial sponsors worried that they would be sued for any bad birth outcomes. While this did protect the trial sponsors, it meant that most of the time, we were totally in the dark about the safety and efficacy of drugs when prescribed to pregnant women.

The fallback has been the “observational trial.” You look at a group who took a given drug and compared their outcomes to a group who did not.

The enormous problem with observational trials is that they are often comparing apples to oranges. People who take a medicine on their own are not the same as those who do not.

Let us take acetaminophen as an example. We know that about 60% of women take it during pregnancy. Most of the trials that report more neurodevelopmental disorders (autism, ADHD) in acetaminophen users compare women who used it with those who did not.

What is the commonest reason for acetaminophen use? It is fever. Thus, acetaminophen users are much more likely to have had febrile illnesses than those who did not use it. If there is an increased incidence of autism among users, the culprit might just as easily be the febrile illness, not the drug.

Until someone – and realistically it will have to be the NIH, as no commercial firm will pay for it – does a controlled trial comparing pregnancy outcomes among women who take acetaminophen with those who take a placebo, we will be offering advice either way with imperfect data.

The closest I can find to a good study is one out of Sweden that used successive pregnancies of women who had more than one child, comparing the siblings and looking at acetaminophen use. This study found no increase in autism, ADHD or learning problems caused by acetaminophen use. Again, though, this was an observational study.

Strengthening this conclusion is a similar study reported this year from Japan that also concluded there was no association of acetaminophen use and autism or ADHD.

Given this, what is the best advice you can take?

First, as is true for all medications, take medication only when you need it. A temperature of 99.6 does not need treatment. A temperature of 102 is harmful to the fetus and should be treated. If you have a backache that can be relieved with heat or a backrub, skip the pills. If you are very uncomfortable, acetaminophen is clearly safer than anti-inflammatories such as ibuprofen or naproxen, that are known to cause fetal malformation, or narcotics.

Second, try to take it for as short a time as possible. The limited data we have suggests that chronic use is worse than occasional use, and that makes physiological sense.


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Does the MAHA movement truly care about America's children?

The Trump administration recently released a long-promised report decrying the sorry state of the health of American children and saying how it planned to change this.

They correctly begin by noting that “Despite outspending peer nations by more than double per capita on healthcare, the United States ranks last in life expectancy among high-income countries – and suffers higher rates of obesity, heart disease, and diabetes.” Unfortunately, they then largely focus their prescriptions on the wrong solutions.

The four areas on which they propose to work to improve our children’s health are ultra-processed food; chemicals in our environment; the lack of exercise due to the digital age; and over-medication and excessive vaccination.

I support (and have written about) reducing the over-abundance of ultra-processed food, particularly the use of high fructose corn syrup in our diet, but to date the RFK Jr-run FDA has spent its energy on trivia such as red food coloring rather than going after big agriculture and big food.

Our food supply does contain too many pesticides, but hunger and malnutrition threaten more American children than do pesticides, and the gutting of the social safety net by the Trump administration will make this problem worse.

More exercise is good for us all, children and adults, so we should be expanding access to outdoor spaces, including national parks, not limiting them as has been done with cutbacks to the National park service.

What is most telling about this report is what it does NOT cover. The chemical that is the biggest threat to health is nicotine and the carcinogens in cigarettes, but there is not a word in this report about tackling the problem of youth vaping, which has been shown to lead to nicotine addiction and life-long smoking.

The insistence on reducing childhood vaccination, a cause that has made millions for Kennedy through his referrals of plaintiffs to class-action suits, is an enormous threat to children’s health. The disinformation spread by Kennedy and his allies has led to reduced rates of vaccination. Fewer children are being vaccinated, which means that diseases once thought eliminated, such as measles and whooping cough, are already making a resurgence. Thousands of American children, and millions world-wide, will die if the anti-vax movement holds sway.

Finally, no mention in the report is made of the leading cause of death in U.S. children and adolescents: death from motor vehicle accidents and firearms. Unlike every other western country, an American teenager is much likely to die by suicide or homicide with a gun than from illness. If RFK Jr and his followers truly cared about America’s children, gun control would be top of their priority list. Its absence says it all.


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How much protein do I need?

Protein has become America’s nutritional obsession, and protein bars have become a $2 billion/year business.

The World Health Organization and the American National Academy of Medicine recommend that we get 0.8 grams/kg body weight daily. For a 180 lb. person, that would translate to about 65 grams of protein daily. At least 85% of Americans already get that much.

For reference, 6 ounces of chicken give you 53 grams of protein while 6 ounces of salmon or lean hamburger give you 44. A 6 oz container of Greek yogurt supplies about 14 grams.

Vegans must be more careful, but an ounce of almonds supply 6 gm, 8 oz of soy milk give 7 and 6 oz of tofu contain 14 gm protein.

Does anyone need more protein? If you are working out vigorously trying to build muscle, upping your protein intake probably helps, but only up to double the recommended 0.8 gm/kg intake, with no added benefit no matter how much more protein you consume.

Older adults often lose muscle mass. The greatest way to avoid this is with resistance training (lifting weights). There is some evidence that modest increase of protein intake, to about 1.2 gm/kg/day may help, but the key is exercise, not diet.

What about protein bars?

They can be an easy way to get calories and protein if you cannot eat a normal meal. Think long hikes or gym workouts squeezed in at lunch hour. They are certainly easy to carry.

Be careful to read the ingredients. Manufacturers can slap a “high protein” label on anything, and the majority of “energy bars” are glorified candy bars, loaded with sugar and ultra-processed. Some of the better options are Clif Bars, RxBars and Rise protein bars, but even the better bars are not as good as a balanced meal with natural protein.

Excess protein can be harmful to the kidneys, so keep your protein intake to no more than 1.6 gm/kg/day (130 gm for a 180 lb. person – proportionally more or less depending on your weight).


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What's the story on Covid shots?

There was a surge in Covid infections this summer, and most predictions are for another in the coming winter. We are also facing flu and RSV outbreaks as surely as the sun rises.

The best defense against respiratory viruses is immunization.

While nothing is guaranteed 100% safe, vaccines offer the best combination of effectiveness and safety of any medical procedure offered.

Upsetting all our plans for combatting the viruses is the chaos sown by RFK Jr, our conspiracy-theorist Secretary of HHS.

Unless you have decided to ignore all available news media, you must be aware that Kennedy summarily fired the entire expert committee that was meant to advise Americans on which immunizations to receive and more recently arranged to fire the head of the CDC (Communicable Disease Center) because she refused to endorse his unsupported anti-vax ideas.

While Kennedy has zero medical or scientific training on which to base his opinions, he has made millions of dollars in recent years peddling his conspiracy theories, both as salary from the Children’s Health Defense group he founded and from generous “referral fees” paid to him by law firms when he sent plaintiffs to them claiming injury from vaccines.

The upshot is that while in past years, Covid boosters were recommended for all, Kennedy’s hand-picked FDA staff recently approved them only for people over 65 or those with medical conditions that put them at high risk for severe outcomes from Covid.

What does that mean in practical terms?

If you are over 65, you can get the shot just as in past years: from your doctor, at a community clinic or at your local pharmacy.

There is a long list of qualifying conditions that put you at high risk. Some are obvious, such as HIV, blood cancer, diabetes and immunodeficiency, which affect only a small number.

However, the list includes many other less obvious conditions that are common: obesity, current or past smoking, physical inactivity and current or recent pregnancy.

In many states, the chain pharmacies have dropped their “come on in, it is free” approach of prior years, fearing they will not be reimbursed under the new guidelines. If you fit one of the broad groups that I listed, you may have to get your shot at a medical office or ask your doctor’s office to send you a prescription outlining your eligibility to take to the pharmacy.

It is worth the extra effort. While most of us by now have been vaccinated and/or been ill with Covid, you CAN catch it again (and again) as it mutates, and vaccination is the best way to ensure it is a nuisance rather than a serious illness.


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