Graphic credit: Tim Robinson
Jane Brody on health and aging.
The New York Times, July 10, 2013
Kidney disease doesn’t get the attention, funding or concern associated with cancers of the breast or prostate. But it actually kills more Americans — 90,000 a year — than both malignancies combined.
Even when it is not fatal, the cost of treating end-stage kidney disease through dialysis or a kidney transplant is astronomical, more than fivefold what Medicare pays annually for the average patient over age 65. The charges do not include the inestimable costs to quality of life among patients with advanced kidney disease.
Much is known about who faces the greatest risks of developing chronic kidney disease and how it can be prevented, detected in its early stages, and treated to slow or halt its progression. But unless people at risk are tested, they are unlikely to know they have kidney disease; it produces no symptoms until it is quite advanced.
Perhaps no one knows this better than Duane Sunwold, 55, a culinary arts instructor at Spokane Community College in Spokane, Wash., whose compromised kidney function was not uncovered until a blood pressure crisis landed him in the hospital. A physician assistant found that abnormal amounts of protein were spilling out in his urine.
Mr. Sunwold, then only 43, was referred to a nephrologist, who diagnosed a condition called minimal-change disease: damage to the tiny blood vessels within the kidney that filter wastes from the blood to make urine. Protein is not supposed to be among those wastes. Although Mr. Sunwold’s personal physician was treating him for high blood pressure, a leading cause of kidney failure, the doctor never checked to see how well his vital organs were functioning.
Such a lapse is hardly uncommon. Kidney disease often is not on the medical radar, and in as many as three-fourths of patients with risk factors for poor kidney function, physicians fail to use a simple, inexpensive test to check for urinary protein.
This fact has turned Mr. Sunwold into a proselytizer with a potentially lifesaving message for 26 million Americans who have kidney disease (many of whom don’t yet know it) and an additional 76 million at high risk of developing it: Make sure your doctor checks the amount of protein in your urine at least once a year.
After his diagnosis, Mr. Sunwold brought all his risk factors under control and succeeded in improving his kidney function. He offers tips online and recipes for good kidney health, which are also good for the heart, diabetes and weight control.
A study published in April online in The American Journal of Kidney Disease demonstrated how common lifestyle factors can harm the kidneys. Researchers led by Dr. Alex Chang of Johns Hopkins University followed more than 2,300 young adults for 15 years. Participants were more likely to develop kidney disease if they smoked, were obese or had diets high in red and processed meats, sugar-sweetened drinks and sodium, but low in fruit, legumes, nuts, whole grains and low-fat dairy.
Only 1 percent of participants with no lifestyle-related risk factors developed protein in their urine, an early indicator of kidney damage, while 13 percent of those with three unhealthy factors developed the condition, known medically as proteinuria. Obesity alone doubled a person’s risk of developing kidney disease; an unhealthy diet raised the risk even when weight and other lifestyle factors were taken into account.
Overall, the risk was highest among African-Americans; those with diabetes, high blood pressure or a family history of kidney disease; and those who consumed more soft drinks, red meat and fast food.
In commenting on the study, Dr. Beth Piraino, president of the National Kidney Foundation, said, “We need to shift the focus from managing chronic kidney disease to preventing it in the first place.”
Which is exactly the approach Mr. Sunwold has adopted. “I had been feeling like I had the flu — bone-tired, exhausted all the time,” he said. “I’m now a wannabe vegan. Meat makes up less than 5 percent of my diet. In just two weeks after changing my diet to one that is plant-based, I really felt much better.”
He also swims laps every day and maintains his 6-foot frame at 180 pounds. His kidney function, which is now normal, is checked every three months, and he religiously takes medication to control his blood pressure.
Dr. Leslie Spry, director of the Dialysis Center of Lincoln in Nebraska and another online proselytizer for a kidney-healthy lifestyle, noted that people with high blood pressure, Type 2 diabetes or obesity who manage to avoid a heart attack or stroke remain at risk for kidney disease, which he likened to the third rail.
Having just one risk factor raises the chances of developing kidney disease from one in 10 to one in three, Dr. Spry said.
A family history of kidney disease is not the only genetic risk. In addition to African-Americans, Hispanic Americans, Asian-Americans and American Indians are more likely than white Americans to develop kidney disease.
“People can’t change their genetics,” Dr. Spry said in an interview. “But I wouldn’t have to work so hard if they didn’t smoke, reduced their salt intake, ate more fresh fruits and vegetables, and increased their physical activity. These are things people can do for themselves. They involve no medication.”
He also urges everyone with any risk factor for kidney disease to be screened annually with inexpensive urine and blood tests. That includes everyone 65 and older, for whom the cost is covered by Medicare. Free testing is also provided by the National Kidney Foundation for people with diabetes.
The urine test can pick up abnormal levels of protein, which is supposed to stay in the body, compared with the amount of creatinine, a waste product that should be excreted. The blood test, called an eGFR (for estimated glomerular filtration rate), measures how much blood the kidneys filter each minute, indicating how effectively they are functioning.
Anyone found to have kidney disease should be referred to a nephrologist, a specialist who can work with the family physician to control the disease.
Two medications commonly used to treat high blood pressure can often halt or delay the progression of kidney disease in people with diabetes: angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Careful control of blood sugar levels also protects the kidneys from further damage.
Health Plan Cost for New Yorkers Set to Fall 50%
The New York Times, July17, 2013
Individuals buying health insurance on their own will see their premiums tumble next year in New York State as changes under the federal health care law take effect, Gov. Andrew M. Cuomo announced on Wednesday.
State insurance regulators say they have approved rates for 2014 that are at least 50 percent lower on average than those currently available in New York. Beginning in October, individuals in New York City who now pay $1,000 a month or more for coverage will be able to shop for health insurance for as little as $308 monthly. With federal subsidies, the cost will be even lower.
Supporters of the new health care law, the Affordable Care Act, credited the drop in rates to the online purchasing exchanges the law created, which they say are spurring competition among insurers that are anticipating an influx of new customers. The law requires that an exchange be started in every state.
“Health insurance has suddenly become affordable in New York,” said Elisabeth Benjamin, vice president for health initiatives with the Community Service Society of New York. “It’s not bargain-basement prices, but we’re going from Bergdorf’s to Filene’s here.”
“The extraordinary decline in New York’s insurance rates for individual consumers demonstrates the profound promise of the Affordable Care Act,” she added.
Administration officials, long confronted by Republicans and other critics of President Obama’s signature law, were quick to add New York to the list of states that appear to be successfully carrying out the law and setting up exchanges.
“We’re seeing in New York what we’ve seen in other states like California and Oregon — that competition and transparency in the marketplaces are leading to affordable and new choices for families,” said Joanne Peters, a spokeswoman for the Department of Health and Human Services.
The new premium rates do not affect a majority of New Yorkers, who receive insurance through their employers, only those who must purchase it on their own. Because the cost of individual coverage has soared, only 17,000 New Yorkers currently buy insurance on their own. About 2.6 million are uninsured in New York State.
State officials estimate as many as 615,000 individuals will buy health insurance on their own in the first few years the health law is in effect. In addition to lower premiums, about three-quarters of those people will be eligible for the subsidies available to lower-income individuals.
“New York’s health benefits exchange will offer the type of real competition that helps drive down health insurance costs for consumers and businesses,” said Mr. Cuomo.
The plans to be offered on the exchanges all meet certain basic requirements, as laid out in the law, but are in four categories from most generous to least: platinum, gold, silver and bronze. An individual with annual income of $17,000 will pay about $55 a month for a silver plan, state regulators said. A person with a $20,000 income will pay about $85 a month for a silver plan, while someone earning $25,000 will pay about $145 a month for a silver plan.
The least expensive plans, some offered by newcomers to the market, may not offer wide access to hospitals and doctors, experts said.
While the rates will fall over all, apples-to-apples comparisons are impossible from this year to next because all of the plans are essentially new insurance products.
The rates for small businesses, which are considerably lower than for individuals, will not fall as precipitously. But small businesses will be eligible for tax credits, and the exchanges will make it easier for them to select a plan. Roughly 15,000 plans are available today to small businesses, and choosing among them is particularly challenging.
“Where New York previously had a dizzying array of thousands upon thousands of plans, small businesses will now be able to truly comparison-shop for the best prices,” said Benjamin M. Lawsky, the state’s top financial regulator.
Officials at the state Department of Financial Services say they have approved 17 insurers to sell individual coverage through the New York exchange, including eight that are just entering the state’s commercial market. Many of these are insurers specializing in Medicaid plans that cater to low-income individuals.
North Shore-LIJ Health System, the large hospital system on Long Island, intends to offer a health plan for individuals as well as businesses for the first time. Some of the state’s best-known insurers, UnitedHealth Group and WellPoint, are also expected to participate. Insurers may decline to participate after they receive approval for their rates, but this is unlikely.
For years, New York has represented much that can go wrong with insurance markets. The state required insurers to cover everyone regardless of pre-existing conditions, but did not require everyone to purchase insurance — a feature of the new health care law — and did not offer generous subsidies so people could afford coverage.
With no ability to persuade the young and the healthy to buy policies, the state’s premiums have long been among the highest in the nation. “If there was any state that the A.C.A. could bring rates down, it was New York,” said Timothy Jost, a law professor at Washington and Lee University who closely follows the federal law.
Mr. Jost and other policy experts say the new health exchanges appear to be creating sufficient competition, particularly in states that have embraced the exchanges and are trying to create a marketplace that allows consumers to shop easily.
“That’s a very different dynamic for these companies, and it’s prodding them to be more aggressive and competitive in their pricing,” said Sabrina Corlette, a professor at Georgetown University’s Center on Health Insurance Reform.
But some consumers may still find the prices and plans disappointing. Jerry Ball, 46, who owns a recycling business in Queens, said the cost of covering his family increased so rapidly in the last few years that he had to scale back their coverage. Still, he pays nearly $18,000 a year for a high-deductible policy for a family of three.
He said he would be reluctant to part ways with his insurer, Oxford, and was disappointed that even the least expensive Oxford plan being offered next year would cost about as much as he pays now.
With another plan, he said: “Will I be able to maintain my doctors? I’m concerned that some of the better doctors aren’t going to take health insurance.”
He acknowledged that the new law would allow him for the first time to easily switch plans, but it is still hard for him to believe it guarantees coverage for pre-existing conditions. “I have to be careful. I can’t be denied coverage, right?” he asked.
The Peoples’ Park, Central Park NYC (Manhattan), Summer of 2013
The Peoples’ Park, Central Park in NYC, One of the World’s Largest Public Parks
Glorious Central Park NYC Summer of 2013
Boating in Central Park, NYC (Manhattan) Summer of 2013