MaineCare Expansion; Signing up

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

August 1, 2018

A bit of history first. The Federal Medicaid Program (called MaineCare here in Maine) was created when its enabling legislation was passed along with the better known Medicare Program in 1968, just as I was graduating from medical school. Before then, all the low-income patients I cared for as a medical student at Boston City Hospital, were dependent for free medical care at city- or county-run hospitals and their clinics, like Boston City, or community hospitals like those around us here in Mt. Vernon, all of which were committed to providing free care to those patients by acceptance of hospital construction monies dispensed through the Federal Hill-Burton program. All 3 Federal programs continue to this day.

More recently, the Federal Affordable Care Act (politicized by calling it "Obama Care", by many), created two new programs: an expansion of Medicaid to include adults under 65 with current annual incomes of less than $16,754 for individuals, $22,715 for couples, and $34,638 for families of 4 (see full tables below), and a "Market Place" where low-income individuals and families with incomes above those and up to 175% of poverty levels could buy Federally subsidized (discounted premiums) full insurance coverage. Over 70,000 people in Maine are getting their insurance through the latter program now but, because the governor has repeatedly vetoed the Medicaid expansion proposals in the name of saving Maine's 10% cost to do so, Maine people who would be eligible, are now left without access to MaineCare coverage. Nearly 2/3 states in the US are participating. Right now Maine income tax dollars are going for supporting the program in those other states but not here.

Annual Income Federal poverty upper limits

Monthly Income Federal poverty upper limits

Having cared for low-income families and studied the impact on their health if they are without insurance (see Mt Vernon Newsletter, October 2017, p5)) for my entire professional life as well as my work as president of Neighbors Driving Neighbors and as town health officer for Mt. Vernon/Vienna, I know how crucial such coverage is if these folks are to be able to find work, care for their children, and remain productive members of our communities. The children are particularly important. 15-20% of children in Maine are now born into such low-income families! The future of Maine will depend on these kids being healthy and succeeding. They can't do that very easily without their and their parents' health! I don't see anything controversial about such a position. As health officer for the town, I want to do anything I can to help that hole in our population's health insurance coverage for those under 65 who are between 100-138% of Federal poverty guidelines.

Maine passed the Medicaid expansion referendum last November with over 60% of the vote. I helped get signatures to support that. Now I'd like to help any Mt. Vernon resident who fits in that category to sign up for Maine Medicaid (MaineCare). If you are not sure, ask me to help you figure it out. As many may know, the legal team at Maine Equal Justice Partners (MEJP) has taken the governor to court to implement the law as passed. It is going to happen sometime within the next year. Those who apply now will get coverage for medical expenses retroactive to the date of their application. So applying now makes sense. In the meantime, those with other insurance coverage should not cancel that insurance until this comes through.

To learn if you are eligible and how to enroll, go to MEJP at: http://mejp.org/content/medicaid-mainecare-expansion-guide, or call 1-866-626-7059.

Or contact me at dkonion@gmail.com, or 293-2076.

About the Influenza Epidemic: Many of You Need to Help Yourselves, Your Family and the Community Right Now. Here’s How.

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

February 2018

People, people, people, many of you I meet are giving up about surviving the influenza epidemic we are in the midst of right now. That’s crazy; please don't!  We’ve got several kinds of arrows in our quiver to help us and ours survive if we are smart enough to use multiple strategies at once, as we do with other complicated challenges.

Please start by going back and reading my piece last November 2017 in the town newsletter, Medical Probabilities Exemplified in Influenza and Car Crashes. It is on p10 though the index in front says p9; go back and read those details; they are important. I explain the presence and impact of probabilities of influenza vaccine on the spread and effect of a “flu” epidemic in our community. It never is all or nothing!  I hate the way the media emphasize one artificial number, “the effectiveness” of the vaccine. I am not even sure how they compute that one number, but it isn’t the whole story and it seems to encourage people to give up. The number they are disseminating now is "30% effective". That should mean that of 100 people, who are exposed to the flu by breathing the viruses into their nose and lungs, 70 will get the flu while 30 won’t. But those aren’t bad odds to start with. We take what we can get and then go from there. So, if you got a flu shot, you are right now that far ahead of your neighbor who didn’t. What they don’t tell you clearly enough, is that of the 70 who get the flu, those who have had a flu shot, nearly all have a better time of it with less severe illness, fewer complications, and not being so sick they are hospitalized or die. Yes, influenza can be a fatal disease and is proving itself to be right now in Maine!

Yesterday I talked about influenza with three people. One, a 70-something friend and carpenter, told me he never got flu shots, didn’t believe in them, and wasn’t getting one despite having had severe pneumonia last year in that milder flu epidemic even though he still had left over lung damage and shortness of breath from it. He, of all people, needs a leg up on this year; I begged him to get the shot. Then there was a young woman grocery clerk with a clearly sputum-producing cough, repeatedly turning to cough away from her customers. Now it could be she just had bronchitis from being a smoker, but that would be unusual at her age and in the midst of a flu epidemic. I bet she had an early influenza infection and will get sicker. Coughing in the other direction simply spread the virus more widely; she should be taught how to effectively cover her mouth with her elbow and/or wear an effective mask, or go home until better. Her employer has a responsibility to have effective education to make this happen. Unfortunately, the Maine Center for Disease Control (CDC), which tries to do that education, has had its budget cut to the bone; and Congress let the national CDC shut down during the budget fight. So we may be on our own. The 3rd example was a mother of a 1-year old who didn’t “believe in” flu shots for her kid. My God folks, this isn’t a belief issue; it’s the science that got us to the moon, dropped mortality rates in this country so most of us get to see age 75 now, and redesigned cars and roads so motor vehicle deaths have plummeted over the last 50 years!

First, you’ve got to understand and recognize two things:

•What influenza is and what it is not. It is not simply a cold with sore throat and temperature under 100 degrees and the person still able to function. Nor is it predominantly nausea, vomiting and diarrhea from gut germs, and which we also call “flu.” Rather, it is a specific viral infection of the lung itself, caused by several related influenza viruses which characteristically change their protein coats as they rip through the population each year. That way people, who have previously been infected, have less resistance because the blue coat antibody (antibodies are the swords our blood cell soldiers use) their body produced by infection with the blue coats last year don’t work as well against the red and purple coats the little devils have switched to. Still, they do work some in slowing down the severity of the resulting illness.

•The vaccine immunizes against 4 different types of influenza viruses this year (that’s what “quadrivalent” means) because these sneaky devils run in packs. Each of those shot elements have varying efficacy. But again, you take what help you can get, and shouldn't let the perfect be the enemy of the good. We have designer vaccines with higher doses for older people, many times also now on immune-suppressant drugs for our chronic diseases like me, and who are harder to make immune, so we need double doses of the vaccine at a time. Childhood vaccines under age 2 are similarly specific to that age group. Get a flu shot now, if you haven’t already this fall or this month. This epidemic is going to go on until spring, April or even May, guaranteed. They all peak in late March with the maximal snow depth no matter the year.

Second, recognize and know about the 3 ways people get sick with the flu and how to take care of them.

•Super sick fast patients: these are usually young people over 4 but under 40, mostly teenagers and young adults with young families of their own, kids often bring it home from school, who haven’t seen as many winters as us oldies and thus have a narrower spectrum of past body experience with the shifting devils. They get sick one night with chills, sometimes but not always have a fever over 101, become prostrate within hours, always have cough, which may not produce sputum; their lungs “white out” (fill with fluid) by X-ray, they often get confused, turn blue and will/can die within hours, often overnight. If you see these signs, get to an emergency room ASAP, do not delay!! Rare but extremely dangerous, the ones you hear about on TV right here in Maine now.

•Then there is another other group with delayed symptoms, especially in the young and old patients, who get the flu with fever over 101, productive cough, feel rotten all over, may have some vomiting, rarely diarrhea, who are having bad influenza that then allows a secondary bacterial pneumonia to grow in the lung mess the flu made. They start to get better after 3-5 days then relapse back with high fever, get sicker again, with more cough, more sputum, if they are strong enough to produce it, and can die in a few more days if not diagnosed and treated with bacterial antibiotics. They go to the ER as soon as that bounce back to bad happens

•Finally, for the rest of the population, with sore throat, fever chills the next day, feel lousy, try to work still, which exposes more friends and neighbors, then gradually improve over a week and get back in the saddle.

Third, there are effective medical interventions that work and help those in the 2nd and 3rd bullet groups. You can prepare for using them by asking your doctor or nurse to consider giving you a written prescription for oseltamivir (Tamiflu) 75 mg to have on hand to fill if you get sick.  You take this twice a day for 14 days and start within the first 48 hours of classic symptoms of the real flu. Many clinicians will want to test a throat swab before prescribing Tamiflu but when the epidemic gets bad, most will figure hoof beats mean horses and do it even over the phone if your case sounds good enough. Also, by taking Tamiflu when you have been exposed to someone living in your house with influenza, one pill a day for 7 days can decrease the likelihood you get it and certainly reduce the rate of complications.

And finally, think of your family, friends and neighbors. Don’t work or visit with them if you can help it, when you are sick. Not 100% effective because you are spreading the virus a couple days before you get really sick, but still can help others.

That’s all: Get a flu shot now if you have not. Avoid people sick with the real flu if you can. Know the 3 different patterns of illness when you or family get it. And be prepared to soften the blow with Tamiflu.

Aging In Place

from

September, 2018

by George Smith and Dan Onion

Dan: George, I know from your recent columns that you are very interested in “aging-in-place” issues for both personal and public reasons. I’d like to hear a little more about why and how because as the health officer for both your and my adjacent towns and a boarded geriatric physician, I too have been been working on ways to help seniors stay here in their homes and among their friends and acquaintances. Tell me what you’ve been doing.

George: Our rural communities are full of old folks, so that is a new and important focus for many of us, including those of us working on a new comprehensive plan for Mount Vernon. A group recently formed a committee to work on initiatives for the elderly. Townspeople appropriated $1000 at the June town meeting for this new initiative. A few of us attended an AARP seminar on their programs for the elderly and were very impressed. Mount Vernon will be applying to join the AARP project soon. 200 towns are already participating in the AARP initiative that is called Building an Age-Friendly Community.

Dan: I’ve been working for the past 3 ½ years to establish a volunteer transportation system in our 2 towns and 3 contiguous ones. Four years ago, Sandy Wright and I happened to have coffee together at the Mt Vernon community center, where she told me that transportation solutions for seniors, who had had to retire from driving were the number one concern of a senior gathering at the local school. From there, she and I recruited a group of interested townsfolk, studied the issue, did some surveys of our seniors, and obtained a Maine Community Foundation 1-year planning grant. That grant let us pull together some focus groups to define the problem and explore some possible solutions, as well as hire Jo Cooper and a colleague from Ellsworth to consult with us about our plan. Jo has been a running service there for nearly 20 years. And, by the way, you probably know her brother Matt Dunlap, the secretary of state, who thereby is in charge of the Bureau of Motor Vehicles. Having served as chair of the BMV medical advisory committee for 5 years in the recent past, I know how interested they are in finding ways to help those whose health requires them to retire from driving themselves.

  Out of that planning arose Neighbors Driving Neighbors, our 5-town volunteer driving service, which has now, after 2 ½ years has given over 1000 rides to local residents, mostly seniors who can no longer drive. Starting with about 20 drivers, we now have over 45 volunteer drivers. A couple startup grants from the Bingham Betterment Fund and the Bingham Program got us going and we now seem able to survive with donations and charitable contributions from individuals and local businesses. Two part-time, very modestly paid local contracted coordinators field the ride requests and find driver matches. We are now giving about 40 rides a month, and last summer gave over 60. Initially most rides were for medical appointments, but we’ve been able to grow the percentage for other social activities up to nearly 50%.  Both are important, we think.

George: Neighbors Driving Neighbors is a great project, and I thank all who are participating, especially you and Sandy. And yes, Matt Dunlap is a good friend of mine. AARP offers community challenge grants to create vibrant public places, and we hope to get a grant for our library, where we hope the addition will become just that – a vibrant public place – for all members of our towns, from kids to senior citizens.

Dan: I never realized, until I got old myself, how complicated it is to plan for contingencies. When will I need driving help. When with housecleaning? When with plowing? When with meals. Can I stay in my house, etc.? And how do I keep up with friends and find new ones as others pass on or move away? I admire your planning and think your example and explicit reporting are helpful to many. In the old days, and occasionally still, multiple generations living in the same or nearby houses made all these choices much easier, but such arrangements are getting rarer, with smaller families, and adult children having to move out of state to find work. Strong, innovative communities seem to find a way to broaden support beyond immediate family members, as I see with Neighbors Driving Neighbors. Ours is one such community to be proud of.

George: One project that we need to tackle comes from the Red Cross. A local volunteer comes to your home to check on your smoke detectors, and they replace them if that is needed.  Both Wayne and Readfield participate in AARP’s program. I have friends who volunteer for Readfield’s Handy Helpers project, ready to help with things like moving furniture or taking things down from high shelves. With my illness of ALS, I must say it is wonderful to live in such a caring community, where many have volunteered to help Linda and me whenever we need help. Four friends came all winter to help Linda shovel. We are blessed.

From Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

Flu shots and other adult immunizations

“Tis the season” to get flu shots and while you are at it, consider other immunizations you and your family may also need.

First, a brief reminder about flu shots. Influenza is an upper (bad colds) and lower respiratory (pneumonias) tract viral infection. It is not a gastro-intestinal infection, although we colloquially say someone with vomiting and diarrhea has “flu” as well; they are not the same infections. Influenza changes its stripes (surface protein antigens) nearly every year, thereby being able to re-infect people who have had flu in previous years. In adults the vaccine is given intramuscularly, or less effectively, beneath the skin, subcutaneously, if anticoagulants might cause too much muscle bleeding. It is a killed vaccine, meaning there are no live virus particles in it, only dead viral cells and bits. Those bits induce your body to make antibodies, circulating influenza virus bullets, over the 2-3 weeks after the shot, so viruses entering your body thereafter are mowed down in large numbers, though not 100%. A few get through and may still cause illness, albeit milder. Children over 2 can get a live virus vaccine in nose drops.

The best way to treat this common disease is to boost your immunity with a flu shot, so you don’t catch it or get only a mild case. The vaccine is reformulated each year, usually with 2 influenza type A variants and one type B by the US Centers for Disease Control, which bases what they tell manufacturers to put in the vaccine on their best guess of which sub-types are around and most infective. The vaccine is egg-based, so the rare person who is truly egg protein allergic (I’ve never met one), can’t take the shot and must use alternatives. Most of us do fine, suffering at most a mildly sore arm. Many claim to have “gotten the flu from the shot,” but this is not possible. Most, I think, are describing a brief aching from the body’s healing up the injection site. Adults and children over 8 need only one dose each year. Children over 6 months and under 8 need a series of 2 shots (or nasal drops if over age 2) at least a month apart if they have never had a flu shot before or have been 2 or more years without one. No immunizations for kids under 6 months; they will have some immunity from their mother still on board from placental transfer and hopefully the family who hugs them all get their flu shots.

The vaccines do work but certainly don’t always prevent infection; in fact you still have a 75% chance of getting influenza, if exposed, even though you’ve gotten a flu shot. But your chances of being so sick you can’t work are reduced to only 60% of what it would have been if you hadn’t had it, because the shot moderates the symptoms. It works even better in the elderly, young, chronically ill (asthma, emphysema, and diabetes) because those groups get much sicker without the shot.

Flu shots cost from $7 in public clinics and some doctor offices, up to $20 at some pharmacies.

And while you are getting your flu shot, consider getting other shots that might make you and your family live longer and/or more comfortably.

First, the combined tetanus/diphtheria/pertussis (whooping cough) killed vaccines as Tdap, where the T indicates an adult dose of killed tetanus cells, the “d” an adequate adult dose of killed diphtheria cells, and the “ap” stands for acellular pertussis proteins without whole dead cells, which cause more side effects. The capital and lower case letters indicate vaccine dose sizes. The disease tetanus, from anaerobic (don’t need oxygen) bacteria that live in dirt, is very rare, <500 cases/yr in the US, but often fatal (60% mortality). The vaccine works extremely well, so it’s crazy not to have a booster every 10 years when your immunity begins to fade. Diphtheria is more prevalent than tetanus but still rare. It used to wipe out whole families before the antibiotic era. Now it’s seen mainly in the alcoholic homeless population. But it is often given with tetanus to try to keep it at bay from everyone. And finally the whooping cough vaccine is important, less for the adults but crucial for infants under 2 years old and to a lesser extent, the elderly, who can also die from it. And we are in the midst of a huge whooping cough epidemic here in Maine right now because our immunity rates have declined. They have declined because many people, especially adults, are not getting boosters, and because the new acellular pertussis vaccine immunity lasts less long, though it has fewer side effects; it replaced the older more potent mercury-preserved cellular dpT. So adults should get a Tdap if they’ve never had an acellular pertussis shot before to protect their very young and old family members and friends, and then a Td subsequently at 10 year intervals. Cost should be similar to the flu shot.

Two other shots are important for older adults. Most important is the Pneumovax shot against pneumococcal pneumonia. People under age 65 need one if they have bad asthma, lung disease, diabetes, or other chronic debilitating disease. All of us need at least one shot soon after age 65, before our ability to respond to it diminishes in our 70s and 80s. Cost is $50-$75. A varicella zoster (the chicken pox/shingles virus) immunization soon after age 60 can diminish the severity and incidence of shingles, which happens more often and causes greater chronic pain in the elderly. Cost should be around $200.

And that’s all, unless you plan to travel to exotic places. Then you should check out travel immunization recommendations for the countries you are visiting at the Center for Disease Control’s very helpful website (http://wwwnc.cdc.gov/travel/).

Dan Onion, MD, MPH

Vienna Health Officer

dkonion@gmail.com

293-2076

9/19/13

Vaping

What is it? Risks/Benefits?

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

January 2019

Devices to deliver heated solutions of liquid nicotine ("e-juice”), mixed usually in propylene glycol or glycerol, have become popular. They are in the form of "pens" which have a reservoir for the nicotine, a heating element to vaporize it, and a battery to do the heating. They thus produce a nicotine-saturated vapor, which is inhaled, hence "vaping". At least 13-15% of adults have now tried this new way to rapidly absorb nicotine into the blood stream, usually not to feed their nicotine addiction but to help them stop old fashioned "burn" cigarettes and thus avoid the 1000s of bioactive chemicals therein, which cause various cancers (lung, head and neck, bladder) as well as ischemic heart disease. Studies so far suggest that there may be some marginal health benefit when these devices are used alone to assist adult smoking cessation as long as they are not used with a few conventional cigarettes daily.  However, public health research shows that most people end up using the two together, and thus suffer the worst of both. Smoking cessation is more safely and reliably accomplished with nicotine patches, gum, or other proven medications, along with group or counselling support (see Vienna Newsletter, Feb-Mar, 2014: p6). Nobody yet knows if passive exposure from "nicotine vapers" is a significant risk to others nearby as it is for cigarettes. The adverse effects of vaping are only beginning to be understood, not surprisingly, since it took us 50 years to prove definitively the bad things smoking tobacco causes.

There are many proven as well as potential dangers to vaping. First, the rechargeable batteries can explode and burn, causing bad burns to the face or inside the pocket they are carried in. Nicotine causes faster heart beats and sometimes arrhythmias like atrial tachycardias or fibrillation. And nicotine itself is of course addicting and thus can prompt withdrawal symptoms, which often lead to higher use and/or use with regular cigarettes. Because the heat vaporized glycerol or propylene glycol liquid nicotine mix produces propylene oxide, formaldehyde, and acetylaldehyde, all known cancer-causing chemicals, most researchers expect that eventually we will see higher cancer rates in chronic or past users. Finally, some of the flavorings, especially sweet and cinnamon ones, added to attract new users to vaped nicotine mixes, break down, when heated, into diacetyl and benzaldehyde, compounds known to irritate the respiratory tract and thus can cause chronic bronchitis.

A second group of accidental or intentional users of vaped nicotine, are children and young adults respectively. The latter are now higher users than adults above age 25; surveys in 2015 reported that 15% of 11th graders had tried vaping nicotine. Nicotine impedes brain as well as global body development in the fetus if the pregnant mom uses either conventional tobacco or vaped nicotine. Accidental nicotine liquid exposure in young children from their eating, inhaling, or getting it on their skin or eyes, is just as bad as their eating real cigarettes; together both are responsible for 1000s of poison control center calls annually in the US. Over half of all such calls for nicotine liquid exposure are in this young age group; many are fatal. In teenagers and young adults up to age 25, studies show impaired judgment and other brain function maturation, and higher addiction rates to nicotine and other substances over time with chronic use. Unfortunately, there are few controls on use by these more vulnerable age groups. I went on Amazon today and could have bought all the equipment and supplies to get started myself for under $50. It's the wild west out there.

Finally, it's not just nicotine that can be used in these vaping devices. Inhaling caffeine and various vitamins this way, judging from the Amazon displays, is popular. Like the liquid nicotine, no one knows the long-term effects of sucking small particles of known and unknown substances into the lungs, but scarring and other damage seems likely over time. Lung replacements come hard. And, of course, liquid marijuana infusions can be taken this way too with rapid and extensive absorption; that too has similar bad effects on brain maturation in the young adult population.

So, my advice is: be cautious, read the surgeon general's report on vaping (https://e-cigarettes.surgeongeneral.gov/); don't vape when pregnant; keep nicotine out of reach of young children; talk about the potential dangers with your teenage and young-adult kids and grandkids. Only opiates and alcohol use present a greater danger to them. I'm sure that someday we'll look back and say, "why didn't people realize this could happen and do something!"

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Merry Dumpster Report

Vienna's total 2018 trash disposal was 205.4 tons; we recycled 82.3ton, which is a total of curbside pickup, recyclable drop off at the transfer station, and our bulky pick up days. These tonnage figures do not include the Universal waste which is also considered toward our recycling percentage. In 2017 our percentage reported to the State was 36.18%; we do not have the 2018 percentage at the time of this report.

Some specific items that we recycled as part of the Bulky Pickup which also includes Universal Waste:

• 10 tons metal
• 45 television
• 10 computers, monitors, printers
• 9.7 tons tires

In the middle of November 2018 Vienna changed from separated recyclable material to single-stream recycling. It is absolutely essential that the rules be followed for what can and can't be recycled. The recycling is being picked up by Riverside Recycling, is taken to Norridgewock Land Fill, and from there EcoMaine Recycling is picking it up. Every load is inspected as it is dumped at Norridgewock and the WHOLE load will be rejected if there is any unacceptable material in the load (and it will become trash). We are still recycling the same materials: paper, glass, cardboard, metal, plastic (not plastic film/bags or styrofoam)

In order to avoid having all of Vienna's recycling rejected, the Riverside Disposal drivers will now check as they pick up the recycling. The drivers are very accommodating, but they can't empty individual plastic bags into the truck. This may result in them not taking an individual's recycling if it contains unacceptable materials. They will leave an OOPS! flyer that explains what is unacceptable. The major problems they have seen are plastic bags and Styrofoam. Please remember:

ABSOLUTELY NO PLASTIC BAGS or FILM or BUBBLEWRAP

(such as SaranWrap®, shrink wrap) – ONLY HARD PLASTIC BUT NO STYROFOAM

Once we get used to the rules, the single stream recycling will make it easier to recycle. EcoMaine has a great tool to answer specific questions about what can and can't be recycled. Here is the link to it: ecomaine.org/recyclopedia

There are three curbside Bulky Pick Up days every year. Universal Waste (batteries, florescent tubes, mercury items, computers, televisions, electronics, and printers) are collected on the bulky days; for 2019 the dates are: Mary 13, July 22, and October 14.

Vienna has done a great job in the past and the Merry Dumpsters thank all the loyal recyclers and composters.

Repectfully submitted

Hillary Hutton and Muffy Floyd