The passage of the Inflation Reduction Act (IRA) on August 12 affects the healthcare of millions of Americans. Provisions will change how certain drug prices get determined, limit out-of-pocket costs for older Americans, and could help ensure continued coverage for Medicaid beneficiaries when the COVID-19 Public Health Emergency ends.
Several provisions of the bill affect Medicare, but beneficiaries who take expensive prescription drugs are likely to feel the biggest impacts. Adults who depend on the American Rescue Plan’s expanded subsidies to afford individual coverage will also experience significant benefits. The bill doesn’t expand eligibility for subsidized individual coverage, so adults who don’t already qualify for reduced-price plans through state or federal marketplaces won’t be affected.
Still, for many Americans, the IRA could meaningfully improve their ability to afford the care they need. “Half of people report difficulty paying for their healthcare or having to make difficult decisions about paying for basic necessities versus prescription drugs or co-payments. That’s where this bill makes some incremental advances that are potentially quite important,” said Dr. Atul Grover, Executive Director of the Research and Action Institute at the Association of American Medical Colleges.
Here’s a breakdown of what the bill does for Medicare beneficiaries, adults who purchase private insurance coverage, and Medicaid enrollees.
For Medicare Beneficiaries
If you have high out-of-pocket prescription drug costs, you could end up paying less out of pocket. The IRA caps out-of-pocket spending on prescription drugs at $2,000 for all Medicare beneficiaries, regardless of income, starting in 2025. This “will probably be one of the more impactful” provisions of the bill, according to Juliette Cubanski, Deputy Director of the Program at Medicare Policy at KFF, a nonpartisan source of health policy analysis. In 2020, 1.4 million Medicare beneficiaries racked up more than $2,000 in out-of-pocket prescription drug spending, according to a KFF report. “Not having an out-of-pocket spending cap potentially exposes people to thousands of dollars in prescription drug costs, especially if they need really high cost medications or have a lot of conditions that require prescription drugs to maintain health,” Cubanski added.
However, with more patients able to afford prescriptions and covering less of the cost, insurers could raise monthly insurance premiums to make up the difference. “Ratcheting that down to a $2,000 maximum provides a lot of help. But it’s going to mean higher premiums for Medicare Part D plans,” said Dr. Alan Sager, a Professor at Boston University School of Public Health’s Department of Health Law, Policy & Management.
If you take prescription drugs covered under Medicare Part D, you could experience savings on prescriptions. Starting in 2026, the federal government will be able to negotiate directly with drugmakers on prices for some prescription drugs covered under Medicare Part D that lack comparable or generic alternatives. The first 10 drugs will be announced in 2023, followed by 15 more drugs in both 2027 and 2028, and 20 more drugs in both 2029 and 2030. Because the drugs haven’t been announced yet, it’s difficult to say “with any level of precision” how many and which categories of patients could benefit from the negotiated prices, according to Cubanski. But negotiated pricing will likely apply to drugs taken by many beneficiaries or that account for significant Medicare spending, such as cancer, rheumatoid arthritis, and diabetes drugs, according to Cubanski.
Starting in 2028, the government will be able to negotiate prices on Part B drugs, which are typically administered by physicians at a doctor’s office or hospital outpatient facility, rather than picked up at a retail pharmacy. Chemotherapy drugs are one example.
If you take any prescription drugs, you could see more stable out-of-pocket prescription drug costs starting in 2024, when a new regulation will interfere with drugmakers’ ability to ramp up prices each year. Under the provision, drugmakers that raise prices faster than inflation will have to pay a rebate to Medicare. Drug price increases do translate into higher out-of-pocket spending for patients, so the rebate is intended to help prevent both of those things from happening. But the bill doesn’t regulate how drug manufacturers set prices for new drugs, which means “manufacturers still have the ability to launch drugs at whatever price they want,” Cubanski said.
If you take insulin, your monthly costs could be capped at $35. Compared to some other countries, patients in the U.S. are “paying 10 or 12 times as much” for insulin, according to Grover. The IRA addresses this with a $35 cap on monthly out-of-pocket insulin costs for all Medicare beneficiaries, starting in 2023. An analysis by KFF found that most Medicare beneficiaries are spending more than $35 on average per prescription.
However, “an important caveat” is that plans won’t be required to cover all insulin products, so some Medicare beneficiaries could end up paying more than $35 per month, according to Cubanski.
If you need vaccinations, your vaccines will be free. Some vaccines, including pneumonia and the flu, are already free under Medicare, but many are not. That will change in 2023, when all vaccinations covered under Medicare Part B will be available at no cost. “This provision will help millions of beneficiaries each year,” Cubanski said. “A lot of these vaccines aren’t super expensive, but when we’re talking about a population that lives on relatively modest income, even a modest out of pocket expense could be burdensome.” The shingles vaccine, for example, is recommended for everyone over age 50, but can cost $50 or more and requires two doses.
If you receive partial financial assistance for Part D coverage, your prescription co-payments will be lower. Currently, low-income Medicare beneficiaries who receive partial financial assistance for Part D coverage typically pay 15 percent coinsurance on prescriptions. But an IRA provision will reduce those copayments to “very modest” flat-dollar copayments of about $1 to $3 for generic drugs and no more than $10 for brand-name drugs, according to Cubanski.
For Adults Who Purchase Individual Coverage Through the Affordable Care Act
If you were eligible for expanded subsidies created by the American Rescue Plan, you could continue to qualify for those subsidies. The American Rescue Plan of March 2021 expanded subsidies created through the Affordable Care Act (ACA) for people who buy health insurance through state and federal marketplaces. The larger subsidies reduced monthly premiums for nearly 90 percent of enrollees, leading to a record 14.5 million people signing up for coverage during the 2022 Open Enrollment Period. With the IRA, those expanded subsidies have been extended for another three years.
According to Sager, the extension will be “vital to prevent returning to the ACA levels of subsidies, which were not big enough to enable many people to afford coverage.” Without the extension, approximately three million people could have lost their ability to afford insurance, and more than 10 million people would have seen their tax credits reduced or lost entirely.
For Medicaid Beneficiaries
You may qualify for a subsidized plan when the Public Health Emergency ends. Under the ongoing COVID-19 Public Health Emergency (in effect since January 31, 2020), states receiving extra Medicaid funding from the federal government are banned from disenrolling people from Medicaid coverage. This strategy has “been effective over the past two years” in keeping people insured, according to Grover. But when the Emergency ends, about 15 million Medicaid enrollees could lose coverage, including two million adults in states that have not expanded Medicaid access to include people in the 100-to-138 percent of poverty range. The IRA’s extension of expanded subsidies for plans available through state and federal marketplaces could help keep them insured through similarly low-cost plans.
Are Transgender People at Risk of Breast Cancer?
People of all genders can get breast cancer, so it’s important for trans men and trans women to consider that as part of their health care.
“Anyone who has breast tissue could potentially or theoretically develop breast cancer,” says Fan Liang, MD, medical director of the Center for Transgender Health at Johns Hopkins Medicine in Baltimore.
Many things influence your breast cancer risk, including your own medical history, any family history of breast cancer, whether you have certain genes that make breast cancer more likely, and whether you get gender-affirming treatment.
There aren’t yet official breast cancer screening guidelines that are specific to trans people. But experts do have general recommendations, detailed below.
You should talk with your doctor about what screening you need, when to start, and how often. Of course, if you notice a lump or other unusual breast change, see your doctor to get it checked out. (“Screening” refers to routine checking for possible signs of breast cancer, not diagnosing what a lump or other change may be.)
Breast Cancer Screening Recommendations for Trans Women
Each person is unique. In gauging trans women’s breast cancer risk, one of the factors that doctors consider include whether they are taking hormone therapy, their age, and for how long. That’s on top of all the other breast cancer risk factors a person might have.
Trans women who take estrogen as part of hormone therapy: If you’re older than 50, get a mammogram every 2 years after you’ve been taking hormones for at least 5 to 10 years.
Not all trans women take gender-affirming hormone therapy. Those who do will develop breast tissue. Any breast tissue can develop breast cancer. And estrogen, which is part of this therapy, does raise the risk for breast cancer.
If you start taking estrogen as an adult, it may not raise your risk as much as if you start taking it as a teen because over your lifetime, you’d have less exposure to estrogen. There hasn’t been a lot of research in this area yet, so it’s not clear how much taking estrogen raises risk for people of various ages.
Trans women with the BRCA1 or BRCA2 genes and/or a strong family history of breast cancer: These genes raise your risk of breast cancer. So it’s very important that you discuss with your doctor how to manage this risk, such as with screenings or other preventive care. You may need to start getting mammograms earlier – and get them more often.
“There are other health conditions, not just cancer, that might not make you a good candidate for estrogen,” says Gwendolyn Quinn, PhD, professor of obstetrics and gynecology at NYU Grossman School of Medicine in New York. “That’s why the decision to use hormones should be overseen by a health care provider, but many trans people don’t have access to a clinician and buy their hormones on the internet.”
If you aren’t taking gender-affirming therapy but are considering it, make sure your doctor knows that you are BRCA-positive.
“It’s not a formal recommendation, but there has been talk about testing trans women for BRCA before starting gender-affirming hormones,” Quinn says. “But a lot of people feel that gender-affirming hormones are lifesaving and that it’s unreasonable to ask that trans women get tested first.”
If you do have a doctor and want to get tested for the BRCA genes – and other genes linked to breast cancer – your doctor can help you find out about what’s involved.
Trans women who don’t take hormones: Although there’s no recommended screening timing, be sure to see your doctor if you notice any breast lumps or changes – and tell them about anyone in your family who’s had breast cancer.
Trans women who got breast augmentation: Some trans women choose to get breast augmentation surgery to create the look of breasts. This is done with implants, fat transferred from another place on the body, or a combination of those methods.
Fat transfer uses your own body fat from somewhere else on your body to create breasts, and studies don’t show that this raises breast cancer risk. Today’s breast implants don’t cause breast cancer, either. They have been linked to a low risk of a rare form of cancer called anaplastic large-cell lymphoma (ALCL). There hasn’t been a lot of research on implant-related ALCL specifically in trans women. But in one review, researchers called it a “rare but serious” complication and recommended being aware of the risk and keeping up with any follow-up care after getting the implants.
Breast Cancer Screening Recommendations for Trans Men
Among the many factors that can affect your risk are whether you’ve had “top surgery” to change the appearance of your chest, whether you take testosterone, and whether you have certain genes that make breast cancer more likely.
Trans men who have not had top surgery or who have only had breast reduction: Get a mammogram every year or two starting at age 40.
If you haven’t had top surgery, your breast cancer risk is the same as it was before you transitioned. That’s true whether or not you’ve had a hysterectomy (surgery to remove your uterus). Removal of the ovaries and uterus only somewhat lowers breast cancer risk. Removing the breasts makes the biggest impact on breast cancer risk.
Trans men who have had top surgery: You may not have enough breast tissue to put in a mammogram machine, so your doctor may recommend that you do self-exams and also get breast exams done by a doctor.
Not every trans man gets top surgery. But some do. Top surgery lowers breast cancer risk, but not as much as a mastectomy you’d get to prevent or treat breast cancer.
With a breast cancer mastectomy, the goal is to remove as much breast tissue as possible, including tissue under the arms and on the ribcage. With top surgery, the aim is different: to change the chest’s appearance to be flatter. “The breast mass is removed, but we don’t go after every single cell because it’s not necessary to do that in order to get the overall result that we want,” Liang says.
“How much surgery lowers [breast cancer] risk depends on how much tissue is left behind, including the nipple, where there’s also potential for cancer cells to develop,” Quinn says.
Trans men who have the BRCA1 or BRCA2 gene mutations and have had standard top surgery (but not a complete preventive mastectomy): You may need annual breast cancer screenings. Since you likely won’t have enough breast tissue to put into a mammogram machine, a breast cancer specialist may need to give you a chest exam. It’s important that your doctors know that you are BRCA+ so they can make a preventive screening plan for you based on how much breast tissue you have.
Trans men who take hormone therapy with testosterone: Testosterone suppresses estrogen. So if you take hormone therapy with testosterone consistently over time, your breast cancer risk is likely to be somewhat lower. But if you don’t take testosterone – or if you only take a low dose or take it intermittently – you won’t have that protective benefit.
Regardless of whether or not you take testosterone therapy, there is still at least some risk for breast cancer. Your doctor can advise you about what screening you need.
Finding Gender-Affirming Care
While experts can make recommendations about cancer screenings for trans people, finding a gender-affirming health care provider is easier said than done in some places.
The World Professional Association for Transgender Health has an online directory of providers of gender-affirming care. You may also simply call doctors in your area and ask about their experience with providing care to trans patients.
“If you can’t find a transgender health clinic near where you live, call the doctor beforehand,” Liang says. “Ask about the provider’s experience with transgender preventive care. See how they respond to the question – whether they have an understanding of what you need or whether the question seems to them to come out of left field.” Your health concerns – about breast cancer or anything else – should be taken seriously and treated with respect by your health care team.
Original Article: webmd.com
Modified Purple Tomato May Be Coming to Your Grocery Store
Sept. 23, 2022 — No matter how you slice it, a genetically engineered purple tomato just got one step closer to showing up in U.S. grocery stores.
The U.K. company developing the new purple fruit has passed a first test with U.S. regulators, demonstrating that genetic changes to the tomatoes do not expose the plants to a greater risk for pest damage.
The purple tomatoes are the first to pass the new SECURE law in the United States. The SECURE Act became law in phases between May 2020 and October 2021. The new U.S. Department of Agriculture (USDA) rules update how the agency reviews genetically modified foods, focusing more on the food itself than the process used to create it.
More Than Skin Deep
Not to be confused with tomatoes with purple skin only, the tomatoes are purple inside and out. Genes taken from the purple snapdragon plant provide the color and boost levels of anthocyanins. Norfolk Plant Sciences says the tomatoes contain 10 times more of this antioxidant than ordinary tomatoes, and therefore provide additional health benefits.
Also known as “super tomatoes,” the purple tomatoes can now be imported, cross state lines, and be “released” into the environment. The company plans to provide seed packets to home gardeners once they receive final regulatory approval.
Norfolk used a common agricultural bacterium, aptly named agrobacterium, to deliver the genetic changes to the Micro Tom tomato variety. Next, the company introduced the same changes into other tomato varieties through cross breeding.
Some genetically modified organisms (GMOs) on grocery shelves can be hard to identify. Many are genetically changed to make them easier to ship or to last longer on shelves, but these properties do not change how they look. However, the deep purple tomatoes from Norfolk Plant Sciences will likely stand out in the produce aisle.
Move over, eggplant. You’re not the only purple fruit in town. (And yes, both are fruits.)
A Boost to Food Innovation?
“We are pleased that the USDA reviewed our bioengineered purple tomato and reached the decision that ‘from a plant pest risk perspective, this plant may be safely grown and used in breeding in the United States,'” says Nathan Pumplin, PhD, CEO of Norfolk Plant Science’s U.S.-based commercial arm.
“This decision represents an important step to enable innovative scientists and small companies to develop and test new, safe products with consumers and farmers,” Pumplin says.
The new federal law was designed to encourage innovation while reducing pest risks, says Andrew Walmsley, senior director for government affairs at the American Farm Bureau Federation.
“We have been genetically modifying plants and animals since we ceased being mostly hunters and gatherers,” Walmsley says. “Improved genetics provide a multitude of societal benefits including, but not limited to, more nutritious food.”
Concerns From the Non-GMO Camp
Not everyone is enthusiastic about these new tomatoes.
When asked what consumers should consider, “We want them to be aware that if this is a genetically modified product,” says Hans Eisenbeis, director of mission and messaging at the non-GMO Project, a nonprofit organization in Bellingham, WA, that verifies consumer products that do not contain GMO ingredients.
“GMOs are pretty ubiquitous in our food system,” he says. “It’s important that [consumers] know this particular tomato is genetically engineered in case they are choosing to avoid GMOs.”
There are other ways to get high levels of anthocyanins, he says, including from blueberries.
Eisenbeis considers the SECURE law changes a “deregulation” of GMOs in agriculture, weakening the ability of the USDA’s Animal and Plant Health Inspection Service to regulate these products.
One concern is that the same mechanism used to genetically modify this plant could be used for others and “open up the door potentially for genetic applications that are entirely unregulated,” Eisenbeis says.
Acknowledging there are skeptics of GMO products, Pumplin says, “Skepticism can be a good start to learning when it is followed by gathering solid information. We encourage people to learn about the science-based facts of GMOs and the ways that GMOs can benefit consumers and the climate.”
“In addition, there are many non-GMO and Organic Certified products available on the market, and consumers who choose to avoid GMOs have many good choices,” Pumplin adds. “New products improved with biotechnology will offer extra choices to some consumers who are interested in the benefits.”
How Will They Stack Up?
Passing the first regulatory hurdle from the SECURE rule does not mean the purple tomatoes can start rolling into stores just yet. Regulation from several federal agencies could still apply, including the FDA, the EPA, and other divisions of the USDA. The tomatoes may also need to meet label requirements from the Agriculture Marketing Service.
Norfolk Plant Sciences voluntarily submitted a food and feed safety and nutritional assessment report to the FDA.
Time will tell what further hurdles, if any, the purple tomato will need to overcome before it can form a purple pyramid in your local produce aisle.
“We want to bring our tomatoes to market with care and without rushing them,” Pumplin says.
Does Skin Tone Affect Skin Care?
Our skin performs many roles. It helps manage body temperature, keeps out bacteria and other bugs, and is key to our sense of touch.
Skin unites us all in these common functions, but our skin also varies in ways that show up cosmetically.
Your skin tone can affect how soon you’ll develop wrinkles and sunspots. It can also influence whether you’re more prone to hyperpigmentation, darkened areas on your skin.
Skin tone isn’t simply a matter of race, since people from the same background can have widely varying skin color. Race and ethnicity usually aren’t an accurate reflection of skin tone, says Anna Chien, MD, an associate professor of dermatology at the Johns Hopkins University School of Medicine.
Doctors refer to “skin types” ranging from 1 to 6. Skin type 1 is the palest, which always burns and never tans. Mid-tones, such as type 4, are light brown, tan easily, and rarely burn. The darkest, Skin type 6, is deeply pigmented and never burns. This range of skin types is also called “Fitzpatrick skin typing,” named for the doctor who developed it. It’s based on how much pigment is in someone’s skin and how their skin reacts to sun exposure.
Learn from three dermatologists how skin tone can affect our skin care routines.
Doctors call sun damage “photoaging,” which includes the wrinkles and sunspots that can come with sun exposure.
This tends to happen “a little more quickly” in people who have lighter skin types, Chien says. “And they are more prone to skin cancers.”
In contrast, people with darker skin tones “often do have delay in the signs of photoaging. And they also have a lower risk of skin cancer,” says Julia Mhlaba, MD, an assistant professor of dermatology at Northwestern University Feinberg School of Medicine. “That pigment actually provides sun protection.”
But it’s important to keep in mind that a lower risk of skin cancer doesn’t mean zero risk. “All skin can get skin cancer,” says Shani Francis, MD, a dermatologist in the Los Angeles area.
Misconceptions that people with darker skin don’t get skin cancer are dangerous because that can lead to a delayed diagnosis or misdiagnosis. “We definitely can see skin cancer in darker-skinned individuals,” Chien says. “And unfortunately, because this isn’t often talked about … the skin cancer may be found later when it’s much more progressed.”
In people with darker skin, cancers can also occur in places “where patients typically don’t get exposed to sun, like the bottoms of the hands and the feet,” Mhlaba says.
Universal Need: Sunscreen
All skin tones require sunscreen with an SPF of at least 30 – every day, rain or shine – to help prevent skin cancer and slow photoaging.
“We always recommend sun protection because even in darker-skinned individuals [and in] folks who say, ‘I never burn; I always tan,’ they’re still getting the damage in the skin,” Chien says.
If you’re outdoors for long periods, use at least an SPF of 60, Chien says. Reapply often, especially if you’re active, sweating, swimming, or getting wet.
Physical blocker sunscreens with zinc oxide or titanium dioxide offer the best protection, according to the experts. But on darker skin, these products aren’t always cosmetically elegant.
“It can cause white film on the skin, which is challenging for individuals with darker skin tone,” Chien says. She recommends tinted sunscreens that might better match their skin tone.
Tinted sunscreen may offer further benefits. In darker-skinned people, longer wavelengths beyond UV rays can be more damaging than in people with lighter complexions, Chien says. “The tint can actually protect against a little bit of the longer wavelength that their skin could be more sensitive to,” she explains.
Don’t rely on sunscreen alone. “I always tell my patients sunscreens aren’t perfect,” Chien says. “We need to reapply and combine [it] with other measures.”
That includes wearing sunglasses and long-sleeved shirts, avoiding peak sun, looking for shade, and wearing wide-brimmed hats. She calls it a “multi-modal approach to sun protection.”
And don’t count on SPF in makeup alone to give you enough protection, Chien says. “The SPF they achieve in a lab setting – usually they’re applying a fairly thick amount of that makeup, so it doesn’t really mimic day-to-day use.”
What to Know About Retinol and Retinoids
Regular use of sunscreen and moisturizer can help slow signs of aging. And so can using a retinoid or retinol on your skin.
“These are vitamin A derivatives that can either be purchased in over-the- counter versions or they can be prescribed by a dermatologist at higher strengths,” Mhlaba says. “They do a lot of things: They’re used to treat acne. They can help with pigmentation. But they can also help in terms of smoothing out fine lines and preventing wrinkle formation.”
People with darker skin tones can use higher-strength retinoids but must start slowly to avoid irritating their skin, Mhlaba says. “If they do develop irritation, it can cause hyperpigmentation more easily than in patients with lighter skin types,” she explains.
Her advice: When you start using a retinol or retinoid, apply only a small amount to your face, and do that every few days at first. Follow up with a moisturizer to help curb any skin irritation.
Wearing sunscreen on the face not only slows photoaging, Mhlaba says, but can also help stop hyperpigmentation from getting worse.
Hyperpigmentation can happen in all skin types, but it’s more common in people of color, Mhlaba says.
“It can occur from acne scars or eczema or at sites of trauma, and then there are other conditions that lead to hyperpigmentation, like melasma,” she says. Melasma appears as darker patches of pigmentation, especially on the face.
Sun exposure can worsen hyperpigmentation – another reason why sunscreen is key. Products that can treat hyperpigmentation include vitamin C serum or vitamin C-containing products, glycolic acid, azelaic acid, and niacinamide, Mhlaba notes.
For melasma, dermatologists can also prescribe hydroquinone-based compounds or oral medications.
Dry skin can affect all skin tones. “But if your skin is darker, dry skin is light white, and so there’s more contrast. It’s much more noticeable,” Francis says. That dry appearance comes from the scales of shedding skin.
Darker skin that becomes dry could benefit from “a really good, thick moisturizer, something that could help to rebuild the [skin] barrier,” Chien says.
Don’t judge a product by how thick it looks in the container. What matters more is how thick it is on your skin, Francis says. She suggests looking for ingredients such as ceramides, glycerin, castor oil, petroleum jelly, and hempseed oil.
Smooth moisturizer over damp skin after showering or bathing. “It will keep the water in the skin,” she says.
People of all skin tones can have problems with sensitivity. “Stick with really bland products,” Chien says. Choose unscented products, and stay away from those labeled antibacterial.
“Keep the skin care regimen pretty simple: just a gentle face wash, a bland moisturizer, something with an SPF built in for the daytime, and just a plain moisturizer in the evening,” she says.
People with sensitive skin can spot-test a product behind their ear or upper inner arm to make sure they don’t react to the product, Chien says.
She recommends “not adding in a lot of serums or anti-aging products. A lot of those can be irritants.”
If people with sensitive skin want to exfoliate, “It’s a little more patient-specific in terms of what their skin will tolerate,” Mhlaba says. Physical exfoliators can be too harsh. But “if you’re talking about a chemical exfoliator, I would definitely recommend starting slowly and working up to using it daily, if needed. Sometimes, even just … once a week, depending on the product, could be enough.”
“Look for things with salicylic acid, glycolic acid,” she says. “A lot of topical creams will have that. That is a good way to exfoliate.”
Original Source: webmd.com
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