Issue: 65

June: Reflections on the Medicaid Funding Debate
As the Republican majorities in the House and Senate endeavor to "Repeal and Replace Obamacare" with potentially disastrous consequences for Americans of all ages who rely on Federal Medicaid subsidies, I am trying to understand both sides of the debate. On the one hand, I am sympathetic to Republicans who wish to reign in soaring costs. Why? Because in a "zero sum game" more money for healthcare means less money for other critically important goals such as educating our children, building and refurbishing our roads and bridges, and reducing the national debt we bequeath our posterity. On the other, I sympathize with the Democrats who say that we must protect the most vulnerable. Republicans take a longer-term view while Democrats focus on the here and now. I'm going to stick my neck out and say that both sides are well intentioned.
John A. Schmidt, MD 
While there are many facets to this fascinating and important debate, the main sticking point has to do with how the Federal and State governments share the cost of Medicaid. This is the latest challenge of the Federalism that has made "e pluribus unum" the crucible of our democracy since 1776. As we approach the Fourth of July and reflect on the heated states-rights arguments that echoed in the dusty chambers of Independence Hall in Philadelphia, let us not forget "...that all men and women are created equal, that they are endowed by their Creator with certain unalienable Rights, and that among these are Life, Liberty, and the pursuit of Happiness." Because healthcare is integral to Life, Liberty and the pursuit of Happiness, the current debate tests our commitment to the principles enshrined in our hallowed Declaration of Independence.

By way of background, Medicare and Medicaid were signed into law on July 30, 1965, by President Lyndon B. Johnson. Medicaid provides health coverage to over 72.5 million Americans (one in five) making it the single largest source of health coverage in the United States. In terms of dollars spent, Medicaid spending in 2015 was $545 billion as compared to $646 billion spent by Medicare and $1,072 billion spent by private insurance companies. Whereas Medicare is funded entirely by the Federal Government and beneficiaries with no contributions from the states, Medicaid is jointly funded by the Federal and State governments. According to the medicaid.gov website, "the Federal Government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP). FMAP varies by state based on per capita income and the amount funded by the state."  The minimum FMAP is 50%. According to the Kaiser Family Foundationthe Federal Government paid 60.6% of New Jersey's Medicaid spending in 2016. Good deal, eh?
Not necessarily!  According to the Kaiser Foundation , "Medicaid is the second largest line item in state capital budgets following elementary and secondary education."  For example, in 2012 total Medicaid spending in New Jersey was about $10.3 billion or $9,400 per enrollee.  If you do the math ($10.3 billion x .394), this means New Jerseyans contribute about $4 billion to Medicaid spending, or just over 10% of state annual spending. 

Then came Medicaid Expansion  in 2014, the provision of Obamacare  that by far has done the most to reduce the ranks of the uninsured, especially in New Jersey.  According to the Kaiser Family Foundation , 552,400 New Jerseyans have been added to the Medicaid roles, approximately one-third of current total state Medicaid enrollment. Persons and families with income up to 133% of the federal poverty line qualified for coverage, including able-bodied, mostly working, adults without dependent children.  Patients who relied on free clinics and emergency rooms suddenly had a doctor to call their own. My practice has participated in the enfranchisement of new Medicaid beneficiaries.

Whereas the Federal Government paid 60% of "Traditional Medicaid," it funded all of the expansion. Governor Christie, a Republican, surprisingly agreed to expand NJ Medicaid.  He correctly saw the infusion of federal dollars as an economic boon to our cash-strapped state.  Even so, nineteen states refused to join the expansion.  Why? Because they saw the expansion as a classical "bait and switch" ploy on the part of the Federal Government to lure states into larger Medicaid budgets as the federal subsidy receded.  In their defense, the Federal Government's share of the Medicaid expansion declines to 95% this year and to 90% by 2020. Though still a good deal for the states, coming up with even 10% of the total spend is a challenge for some states with balanced budget provisions.

Let me dispel the notion that Medicaid coverage is "Cadillac Care." Nothing could be further from the truth.  While beneficiaries pay little or nothing, the payment schedule for providers is so parsimonious that most providers have dropped out of the Medicaid network. The physician participation rate in New Jersey is the lowest in the nation.  While I have kept my large panel of Medicaid patients, I have been forced to turn away new Medicaid patients to stay afloat.  As fewer and fewer doctors accept Medicaid, the system is in dire risk of implosion.  If the Federal Government reduces its investment, as currently proposed, Medicaid as we currently know it will become non-sustainable. 

I believe a strong case can be made for continuation of the shared federal-state Medicaid funding model. Most of my Medicaid patients are working and raising families and need the coverage to stay healthy, minimize sick leave, and increase their productivity.  More than 200,000 New Jersey seniors on Medicare also receive Medicaid. Most of them are nursing home residents.  This allows their families to keep their jobs rather than become stay-at-home caregivers.  Medicaid dollars, as acknowledged by our governor, also represent an economic stimulus to our state.  For all these reasons, it is crucial that we reach a bipartisan consensus on the level of Medicaid spending and a balanced funding formula.  In our federal system, states should have the right to tailor their Medicaid programs to suit their own priorities, especially if their citizens are footing a large share of the bill. There is already considerable heterogeneity among the states. Allowing the states to redesign their Medicaid programs creates best practices while giving electorates the opportunity to fund those insurances that most benefit their communities. 
Repurposed Medicines for Weight Loss
One of the recent trends in medical weight loss therapy has been the pairing of older medications which, when taken together, lead to weight loss.  There are two pairs approved by the Food and Drug Administration (FDA) for this purpose.

The first is a fixed dose combination of phentermine and topiramate. Phentermine is an appetite suppressant and central nervous system stimulantTopiramate is an anticonvulsant also used for migraine prophylaxis. Patients can expect to lose 20-25 pounds after one year of therapy. The medication is not recommended in patients with cardiovascular disease, hypertension , hyperthyroidism, glaucoma or during pregnancy. The most common side effects are dry mouth, constipation, numbness, and anxiety.  Women of child-bearing age should have a pregnancy test and observe strict birth control measures to prevent birth defects.  Because topiramate can produce renal stones, it should be used cautiously in patients with a history of renal stones.

The second is a fixed dose combination of bupropion and naltrexone. Bupropion is a well-known antidepressant also used for smoking cessation. Naltrexone is an opioid antagonist used to treat opioid or alcohol dependence. Patients can expect to lose 4-5 percent of body weight. The cardiovascular safety of this combination has not yet been established. Side effects include nausea, headache, and constipation. Because the combination can raise blood pressure and heart rate, bupropion-naltrexone is contraindicated in patients with uncontrolled hypertension, seizure disorder and/or eating disorder.
Cardiovascular and Renal Benefits of SGLT2 Inhibitors in Type 2 Diabetes
SGLT2 inhibitors are proving useful in the treatment of type 2 diabetes mellitus. They work by releasing glucose (sugar) into the urine, about 600 calories worth per day. Unlike other diabetes treatments that lead to weight gain, these medicines typically lead to modest weight loss without risk of hypoglycemia. The two leading medicines in this class,   Jardiance® and   Invokana®, have favorable side effect profiles. 

What has caught the attention of the medical community, myself included, is the beneficial effect these two medicines have on cardiovascular outcomes. Patients with diabetes are at increased risk of heart attack, stroke and kidney disease. Jardiance® was the first to show an improvement in cardiovascular outcomes. Now comes a large study with Invokana®, published online on June 12 in the New England Journal of Medicine , showing that patients had significantly lower rates of a composite outcome including death from cardiovascular causes, nonfatal myocardial infarction, and non-fatal stroke. Patients treated with Invokana® were also less likely to be hospitalized for heart failure or lose kidney function. There was a small but significant increase in amputation rate (6.3 vs. 3.4 per 1000 patient years) comparing the treatment and placebo groups. Thus, diabetics who have had amputations or have severe peripheral vascular disease should probably not use these medicines. Having said this, these medicines are establishing new norms for the treatment of type 2 diabetes.
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!
My wife and I will be celebrating our 39 th wedding anniversary this weekend!! I remember that glorious day like it was yesterday! The temperature in Our Lady of Nebraska Chapel in Omaha was 107 degrees, 115 degrees in the choir loft! And I was late! But we were too happy to care and still are!

Valerie, Morgan, Ms. Clark and I wish our patients and their families a wonderful Fourth of July!! 
In This Issue
June: Reflections on the Medicaid Funding Debate
Repurposed Medicines for Weight Loss
Cardiovascular and Renal Benefits of SGLT2 Inhibitors in Type 2 Diabetes
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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"From every  mountain side
Let Freedom ring."
- Samuel F. Smith, "America ("My country, 'Tis of Thee")


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.