How Will a Trump Presidency Impact Your Health?

No one is sure how the astonishing election of Donald Trump as president will impact health care in the United States. But with the backing of a Republican-controlled Congress, experts are warning Americans — and especially the 20 million who have gained health insurance through the Affordable Care Act  (ACA) — to expect big changes.

Trump has promised to repeal Obamacare (the ACA).

While the Senate may lack the 60 votes needed to completely erase the ACA, it’s clear that Trump plans to challenge the law, which Republican leaders will be happy to help him with.  On the other hand, a number of Republican leaders and Trump himself have said there are provisions that are likely to stay, include keeping coverage for those 26 and younger if they are under their parents’ insurance plan, and banning the bar on people with preexisting conditions from getting insurance.

If all parts of the ACA are eliminated, it could put many Americans’ health in jeopardy.  Doing away with the law could lead to:

• Up to 25 million Americans losing health insurance. These people are primarily working-class, most with a high school or less education. About 40 percent are young adults and half of them non-Hispanic whites.
• Insurances going back to denying coverage for pre-existing conditions like hypertension or cancer, or writing stiff premiums — if they offer coverage at all.
• Young adults under 26 being kicked off their parents’ insurance.
• Death rates rising — people without insurance have about a 25 percent increase in death rates as compared to those who are insured.
• Health care exchanges being eliminated.

Trump wants to give states more freedom about how to allocate Medicaid funds by turning the social health care program into a block grant program.

Sounds good in theory, but increasing state’s latitude of funds on Medicaid dollars — usually in the form of state grants — rarely helps the health of the population.  States who cut back on taxes, and therefore have less revenue, can redirect these block grants to other state needs that are not health-related. The impact of poorer health conditions result in sicker, later arrival to care and increased health expenditures, as well as potentially avoidable, adverse health outcomes or deaths.

Women’s access to abortion could be limited.

Full and comprehensive care for women means women can choose when and if they have children, It means they have access to reproductive services and can have planned pregnancies when it makes the most sense for them and their families.  With so-called Targeted Regulation of Abortion Providers (TRAP) laws, lawmakers have already made it challenging, if not impossible, for many women to have access to safe, legal abortions in many states. In June, the U.S. Supreme Court struck down parts of a restrictive Texas law that could have drastically reduced the number of abortion clinics in the state.

But if enough vacancies arise on the Supreme Court while Trump is president, he could appoint conservative justices, who might tip the balance of the court enough to overturn the legal precedents set forth in Roe v. Wade, the 1973 decision that struck down state laws that banned abortion and formed the bedrock for our current protections of reproductive rights. It is likely that Trump will have to fill one, and as many as three, vacancies on the Supreme Court during his term.

The current political regulations by those in government have made it such that most poor women have little or no access to termination as a reproductive option. So, in fact, repealing Roe v. Wade is likely to affect middle and higher income women more than others. During his candidacy, Trump also promised to defund Planned Parenthood. Further, some women are concerned that a Trump administration might end ACA provisions that require insurers to cover intrauterine devices (IUDs) and other types of contraception.

Mr. Trump has demonstrated his unpredictability. It is not clear he is as aligned with other members of his party, ideologically speaking. Hopefully, recognizing the needs of women, he will not support a war on women and women’s health. Hopefully, he will demonstrate a practical stance in this matter — not one blindly adhering to his party’s most extreme members.

Excerpted from an interview with

Ana E. Núñez, MD

Professor of Medicine, Associate Dean of Diversity, Equity & Inclusion

 

 

Election 2016: Mourning in America

 

Think deeply about the words of Hillary Rodham Clinton -

“This loss hurts, but please never stop believing that fighting for what's right is worth it…

We need you to keep up these fights now and for the rest of your lives.  So let's do all we can to keep advancing the causes and values we all hold dear …  breaking down all the barriers that hold any American back from achieving their dreams … people of all races and religions, men and women, immigrants, LGBT people, and people with disabilities.

 And -- to all the little girls who are watching this, never doubt that you are valuable and powerful and deserving of every chance and opportunity in the world to pursue and achieve your own dreams.”

                                                                                                                                                Judith Wolf, MD

                                                                                                                                      Associate Director, WHEP

While searching for an article to present for my journal club in July, I knew I wanted to talk about something new and relevant to my chosen field of Ob/Gyn. When I came across a recent article in the NEJM published by a group of Maternal-Fetal Medicine physicians, I was immediately intrigued. The article, titled “Antenatal betamethasone for women at risk of late preterm delivery”, is a double blind randomized control trial  (ALPS trial) that assessed if giving women antenatal steroids between 34.0-36.6 weeks gestation decreased neonatal respiratory complications. At the time, I thought this was a very relevant topic as I had just studied for Step 2 CK and encountered many questions that asked about when to give or not give steroids for lung maturity.  The answer for boards was always that before 34 weeks, give steroids, and after 34 weeks, don’t. 

This study aimed to shed some light on what to do about infants who are born in the late preterm period, between 34.0 weeks and 36.6 weeks. There previously had been little conclusive data regarding the benefits of antenatal corticosteroids for fetal lung maturity in this gray area. Study participants were randomized into a treatment group, who received 2 doses of betamethasone 24 hours apart, or a control group, who received 2 doses of a placebo 24 hours apart.  The primary outcome for the study was a composite result made up of several factors: the use of CPAP or high-flow nasal cannula for at least 2 hours, supplemental oxygen with an FiO2 of at least 0.3 for 4 hours, ECMO, or mechanical ventilation. There were several other secondary outcomes including rates of transient tachypnea of the newborn, bronchopulmonary dysplasia, and surfactant use. The study found that the primary composite outcomes occurred less frequently in the treatment group vs the control group (14.4% vs. 11.6%, RR 0.80, 95% CI 0.66 to 0.97, P=0.02). Several of the secondary outcomes occurred less frequently in the treatment group as well.

Very soon after this article was published, the American Congress of Obstetricians and Gynecologists (ACOG) released a practice advisory stating “administration of betamethasone may be considered in women with a singleton pregnancy between 34.0 and 36.6 weeks gestation at imminent risk of preterm birth within 7 days”. I found out first hand just how relevant this new data was on the first day of my OB sub-internship this month, when we had a patient at 35 weeks and 5 days and the attending turned to me and asked “have you heard of the ALPS trial?” Over the past 2 weeks, I’ve seen 3 patients in the late preterm period receive betamethasone based on the findings from this study. It’s pretty cool to see the positive impact of research on daily practice!

 

Article reference: Gyamfi-Bannerman C, Thom EA, Blackwell SC, Tita AT, Reddy UM, Saade GR, et al. Antenatal betamethasone for women at risk for late preterm delivery. NICHD Maternal-Fetal Medicine Units Network. N Engl J Med 2016; DOI: 10.1056/NEJMoa1516783. PMID: 26842679.

Kelly Guttman, MS4

Women's Health Pathway

Work-Life Balance: Is it possible to have it all?

 

            As I begin the dreaded process of applying for residency, I have been deeply thinking about what my priorities are in life. In addition to applications, I am also in the midst of planning my wedding for the spring. Of course I want to have a great learning experience in residency and a successful medical career, but I would also like to be able to start a family. Is it possible for female physicians to have an amazing career and family – can we have it all?

            This is a common problem faced by many women in the healthcare field. As the number of female physicians continues to rise, the challenges that women physicians face in trying to maintain this balance has come to light. The work-life balance is a significant factor in which specialty a woman chooses. There are many specialties where women are underrepresented, especially in the surgical fields and in the academic setting, likely related to difficulty to find balance in these demanding careers.¹ The timing of pregnancy is also a major decision for women. Many factors contribute to this decision, including the program’s policies on maternity leave, the availability of childcare, and even whether the new mom would have a private place to pump breast milk at work in order to continue breastfeeding. One issue with pregnancy during residency is that there is a potential for resentment among co-residents, as physician-mothers may be seen as having special treatment.¹ However, this also needs to be balanced against the a physician-mother’s guilt of leaving her infant at home or daycare as she returns to work. Unfortunately, female physicians who desire starting a family continue to face these (and many other) challenges when entering residency in the medical field.

            In order to make this balance more feasible for women, it would be beneficial for more programs to establish accommodating practices that allow female physicians to tackle the aforementioned challenges. Flexible hours and part-time work are good options to allow women to have more time to manage childcare. Also, there needs to be a decrease in stigmatization of women who decide to take time off for parenting reasons, especially in the surgical fields. It would also be helpful to many mothers if more hospitals provided childcare during working hours. This would allow physicians (and all other healthcare workers) to continue to work and still be nearby to their young children.

            As for me, I hope to find a happy balance between my roles as a physician, wife, and mother in the future. I know it will take a lot of sacrifice to juggle a clinical and academic career with motherhood, but with some flexibility, a lot of hard work, and establishing priorities, you can accomplish everything that is important to you.

 

Reference:

1. Verlander, G. 2004. “Female physicians: Balancing career and family.” Acad Psychiatry 28(4):331-6.

https://www.med.upenn.edu/gastro/documents/BalancingCareerandFamily.pdf

Shelby McLaughlin, MS4
WHEP Pathway Student

While looking at the most recent news stories concerning women's health by searching “women's health” in google news on August 11, 2016, a vast majority of the articles were concerning sex, having babies, weight, and relationships with men. They were mainly about sex positions and zika virus, which may be important, but aren't very representative of all the issues that are important in women's health today. There were a couple particular stories that were more complex though looking at the intersectionality of women's health with other social identities, such as race and transgender issues. One particular article was about the impact of racism on mental health in the magazine website, Women's Health.

 

This Women's Health article appeared to be inspired by the Black Lives Matter movement and the mental trauma of police violence and brutality. A majority of their website article was trying to explain a scientific article in the American Journal of Public Health concerning the mental health risks of daily racial discrimination, and they actually did a fair job of explaining the health, science, and research components. The study actually took place in the UK, but there were a lot of findings and lessons that could be transferable to America. It was a short internet article, but at the end of their discussion of the research, they gave a call to action and steps to address discrimination and racism in America. These included contacting elected officials to keep them accountable concerning race and law enforcement, becoming an educated voter about were candidates stand on these issues, and volunteering for or donating to specific community organizations that have a history of working towards racial equality.

 

It was a good example of explaining scientific evidence to a broad audience including both those that may or may not be experiencing racism themselves as well as connecting it to action. This is something academia often lacks. Publishing articles in scientific journals doesn't mean the American people or the world will learn or benefit from hard scientific work or that social action and policy change will occur. The media plays an important role, but these days they are more interested in entertaining than educating or seeking truth. Explaining science isn't always the most entertaining news, and if they do report scientific findings, they often report on poorly done studies with one sentence headline conclusions unsupported by the findings. Academia has a greater responsibility (actually it should be their main responsibility) to educate the public with quality scientific evidence in a way that different education levels can interpret and appreciate across social identities as well as political and cultural views. Academia must also ensure that their research leads to actual social and policy change as well. These issues concerning the media, academia, and the education system are a part of the problem resulting in our current political climate and presidential election situation.

 

Obviously, there is a long way for academia and the media to go as only a few articles out of a hundred under “women's health” on google news were about complex social, health, and scientific issues. It would be interesting though to see if the magazine website and the researchers collaborated on this article to ensure the conclusions were appropriate and that it was presented in a way to be interpreted across the spectrum of society as well as to explore how often this occurs.

 

http://www.womenshealthmag.com/health/racism-mental-health

Alexander Sloboda, MS 4

Women's Health Pathway

Still Blaming the Victim

No matter which political party you belong to, I think we can all agree that this election season has been like no other in recent history, plagued by an abundance of controversies, accusations, theatrics and faux pas – including some that concern women and women’s health issues.  Part of this past week’s drama involved sexual harassment in the workplace.  Following the resignation of Roger Ailes, former Fox News chief who is accused of sexually harassing many of his female employees, Donald Trump responded to a question about how he would feel if his own daughter were being harassed in this way: “I would like to think [Ivanka] would find another career or find another company if that was the case."                                                                So, just leave and find another job?  Another career?  

Trump’s son, Eric, added that as a strong woman “Ivanka wouldn't allow herself to be subjected to that.”  In other words, women are able to control being subject to sexual harassment.

                               Sexual harassment is a choice?

According to the National Women’s Law Center, one in four women experience workplace harassment but most do not report it for fear of retaliation.   It’s time we stopped placing the blame on women rather than those who harass them and say “you’re fired” to the perpetrator.  And it’s time we elect a president and members of Congress who understand this and do something about it.

                                                                                                                                                    Judith Wolf, MD    Associate Director, WHEP 

 

 

Sex/gender disparities in atrial fibrillation-related stroke risk

  

At a recent European cardiology meeting, a retrospective cohort study¹ was presented which looked at differences in hospitalization rates for acute ischemic stroke among male and female patients with atrial fibrillation over a 15 year period (1998 – 2012).  The study, which included 1.1 million patients admitted to 1000 hospitals in 46 states, revealed that women had a 23% higher risk of being hospitalized for stroke than men after adjusting for such risk factors as age, diabetes, hypertension, previous stroke and heart failure.  In addition, women had a higher risk of stroke compared to men regardless of race, socioeconomic status, or geographic location.  According to the study authors, “women have second-rate outcomes across the board due to inadequate stroke prevention care rather than biological differences”.   Why should this be so?

A previously published, related study² that evaluated over 500,000 Medicare patients (87% white, 41% male) after newly diagnosed atrial fibrillation found statistically significant differences in the receipt of appropriate medical services (e.g. evaluation by a cardiologist, catheter ablation, anticoagulation, use of beta blockers and antiarrhythmic drugs) - especially catheter ablation (female vs male: AHR 0.65; 95% CI 0.63-0.68; P < .001) and receipt of oral anticoagulants (female vs male: AHR 0.93; 95% CI 0.93-0.94; P < .001). 

It is all too obvious that women with atrial fibrillation receive less state-of-the-art therapy for atrial fibrillation and stroke prevention compared to men.  Although the reasons behind this disparity remain uncertain, they likely include differences in presenting symptoms (see illustration) including the absence of symptoms in ~30% of women, delays in seeking medical attention (women are notorious for putting everyone else’s needs above their own), and provider bias (attributing symptoms to panic attacks or stress).  As medical professionals we need to be aware of and eliminate disparities so that we deliver appropriate, personalized care to all of our patients.

                                                                                                    

             Judith Wolf, MD             Associate Director, WHEP

 

1. Ghanshyam Palamaner Subash Shantha; Hardik Doshi; Anita Kumar; Gopi Dandamudi; Prashant Bhave; Alexander Mazur; Denice Hodgson-Zingman; Michael Giudici ‘Gender differences in the rates of hospitalizations for acute ischemic stroke among patients with atrial fibrillation in the United States: A 15 year experience involving 1.1 million patients’ CARDIOSTIM – EHRA EUROPACE 2016.  June 8-11. Nice, France  http://www.cardiostim.com/
2. Bhave PD, Lu X, Girotra S, Kamel H, Vaughan Sarrazin MS. Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation. Heart Rhythm 2015;12(7):1406–1412.
   http://www.sciencedirect.com/science/article/pii/S1547527115003306