RI ARA November 4, 2018 E-Newsletter by RI ARA

RI ARA

Publication 2018 Issue 44 Published in house by the RI ARA

November 4, 2018 E-Newsletter

GOP Continues Rolling Back Protections for People with Pre-existing Conditions GOP Continues Rolling Back Protections for People with Preexisting Conditions Despite Claiming to Champion Them The administration took steps to broaden access to health plans that do not cover preexisting conditions this week, weakening standards and loosening regulations on the health insurance industry. Protections for patients with pre -existing conditions were established by the Affordable Care Act (ACA). Currently, states can apply for permission to redesign their insurance markets and still keep federal aid, as long as the

changes do not decrease the number of people with comprehensive health coverage. With the changes, states could still receive federal funding even if their plans shift people out of comprehensive coverage and into plans that flatly deny coverage for a pre-existing condition, as long as residents still have access to a more expensive, inclusive plan. The rule changes come amid last minute GOP promises to save protections for pre-existing conditions ahead of the midterm elections. While the President stated in a tweet last week that “All Republicans support

people with preexisting conditions,” his administration has made numerous rule changes that allow for cheaper plans offering skimpy coverage and lacking protections. The Department of Justice also refused to defend the ACA in a GOP-led lawsuit seeking to declare the law unconstitutional, stripping away pre-existing protections established under the ACA. Republicans in Congress have repeatedly sought to repeal and sabotage the law’s key provisions, and a repeal bill passed the House last year before being narrowly defeated in the Senate.

“Many Republicans say they will protect patients with preexisting conditions, but Joseph years of actions Peters, Jr. show otherwise,” said Joseph Peters, Jr, Secretary-Treasurer of the Alliance. “The fact is that these protections are at risk of being eliminated. We must vote for elected officials who will support seniors and defend access to affordable health care, regardless of medical history.”

New Prescription Drug Proposal Uncertain to Bring Down Prices at Pharmacy In a press conference with Health and Human Services Secretary Alex Azar Thursday, the President blamed international “free loading” for high prescription prices and announced a new plan to change the way Medicare pays for certain drugs. The proposal still needs to be refined and put through a federal rulemaking process. The proposal has severe limitations, as it would only apply to drugs administered directly at doctors’ offices and

outpatient hospital departments. The vast majority of prescriptions that patients purchase at pharmacies would be excluded from the pricing plans, and most patients won’t see reductions in their prescription costs. The plan aims to keep costs similar to those in sixteen other countries, where prices are on average 44% lower, by slowly decreasing them to international levels over five years. It also calls for private sector vendors to negotiate with drug makers.

Finally, the administration would change the practice that gives doctors a percentage of the drug fee, which can incentivize them to prescribe more expensive medications. Experts expect that the new proposal will face intense opposition from the hospital and drug industries, both of which have powerful lobbying influence. “As we’ve seen in the past, the administration’s plans to bring down skyrocketing prescription drug prices fall short,” said

Alliance Executive Director Richard Fiesta. “This plan is too slow and too Rich limited to make a Fiesta real impact for seniors who are unable to pay for life-saving prescriptions now. We need bold action, such as allowing Medicare to negotiate prices without the restrictions that this plan includes, to address profiteering.”

Rhode Island Alliance for Retired Americans, Inc. • 94 Cleveland Street • North Providence, RI • 02904-3525 • 401-480-8381 riarajap@hotmail.com • http://www.facebook.com/groups/354516807278/

Jimmo Corrective Action Plan Completed step in a courtordered Corrective CMS Adds Resources Action Plan, designed to Regarding Medicare Coverage reinforce the fact that To Help People Who Need Medicare doescover skilled Skilled Maintenance Nursing or nursing and skilled therapy Therapy services needed to maintain a As ordered by the federal judge patient’s function or to prevent or in Jimmo v. Sebelius, the Centers slow decline. Improvement or for Medicare and Medicaid progress is not necessary as long Services (CMS) published a new as skilled care is required. webpage containing important The Jimmo standards apply to information about home health care, nursing home the Jimmo Settlement on its care, outpatient therapies, and, to CMS.gov website. a certain extent, for care in The Jimmowebpage is the final Inpatient Rehabilitation

Facilities/Hospitals. The Jimmo webpage and other elements of the Corrective Action Plan should help ensure that the Jimmo Settlement is implemented correctly and that it opens doors to Medicare coverage and necessary care for beneficiaries who require maintenance care, including people with long-term, progressive, or debilitating conditions. As required by the Court, CMS also provided additional training for Medicare decision-makers. Judith A. Stein, Executive

Director of the Center for Medicare Advocacy, which is lead counsel for the nationwide class of Medicare beneficiaries said, “People living with MS, Parkinson’s, Alzheimer’s, paralysis and other long-term conditions have waited long enough for this relief. We hope that the new CMS education and information, which can be found at CMS.gov and printed out with the CMS logo, will help convince providers that Medicare really is available for people who need this critical maintenance care.” ...Read More

The 2019 Social Security increase will cost some retirees Social Security recipients will enjoy a 2.8 percent increase in their benefits — the largest in seven years — in 2019. But for some recipients, this latest annual increase could end up costing them benefits. Retirees who do not currently pay federal income taxes on their Social Security benefits may owe taxes due to the increase, which is technically known as a cost-ofliving adjustment, or COLA. Retirees who already pay taxes on their benefits may owe more taxes due to the COLA. It depends on how the COLA

impacts what the Social Security Administration calls your “combined income,” a figure that reflects multiple sources of retirement income. It's not the usual blah, blah, blah. Click here to sign up for our free newsletter. How Social Security benefits are taxed The extent to which your Social Security benefits are taxable is based on your combined income. This figure comprises: 1.1. Your adjusted gross income

2.2. Any nontaxable interest One-half of your Social Security benefits In other words, if you add up those three amounts, you will have your combined income. According to the Social Security Administration, you may owe taxes on up to 50 percent of your Social Security benefits if:  ¨ You file a federal tax return as an individual and your combined income is between $25,000 and $34,000.  ¨ You file a joint return and

your combined income is between $32,000 and $44,000.  ¨ You may owe taxes on up to 85 percent of your Social Security benefits if:  ¨ You file an individual return and your combined income is more than $34,000.  ¨ You file a joint return and your combined income is more than $44,000. According to a national survey released by the nonprofit Senior Citizens League earlier this year, about 56 percent of all Social Security households pay taxes on part of their benefits.

102 Million People in U.S. Have Pre-Existing Conditions, Study Says. Here's Why That Figure Is Suddenly Important individuals—not and pregnancy. If tweeted about the issue on More than 100 to mention their you think you Wednesday, claiming that million Americans immediate have a preRepublicans will protect those live with preexisting individuals living with preexisting conditions families—could face higher health condition, well, existing conditions. and are not enrolled in a insurance premiums and you just might. It’s a sweeping The president’s claim is a public health insurance significant out-of-pocket costs categorization that—prior to strange one, given that program such as Medicaid or the ACA’s passage—gave Republican lawmakers have been Medicare. And with the 2018 related to their medical care, according to a new study from insurers cover to exclude the ones fighting to actively midterm elections just weeks national health care research individuals from health dismantle the Affordable Care away, those numbers could Act—not Democrats. It seems and consulting firm Avalere. insurance coverage. signal how voters cast their ballots, with Congress “Protections for pre-existing possible the Trump A pre-existing condition debating whether or not to conditions are the only reason administration’s war on includes most major health Obamacare could be a boon for repeal of the Affordable Care conditions, including some Americans are able to Democrats come the midterm afford health insurance,” Act. cardiovascular disease, diabetes, and obesity, as well Avalere’s director Chris Sloan elections on Tuesday, November If the ACA, also known 6. said in a statement. as Obamacare, is r epealed, a as a variety of mental health President Donald Trump conditions and even arthritis total of 102 million Rhode Island Alliance for Retired Americans, Inc. • 94 Cleveland Street • North Providence, RI • 02904-3525 • 401-480-8381 riarajap@hotmail.com • http://www.facebook.com/groups/354516807278/

Trump Rollback Of Disability Rules Can Make Doctor’s Visits Painstaking Going to the doctor’s office can feel so routine. You sit in the waiting room, fill out the paperwork, get measured and hop onto the exam table. But medical appointments for patients with disabilities require navigating a tricky obstacle course, full of impediments that leave them feeling awkward and could result in substandard care. Despite laws that require ramps and wider doors for access, many health care providers don’t have scales that can accommodate wheelchairs, or adjustable exam tables for patients who can’t get up on one by themselves. Dr. Lisa Iezzoni, a professor of medicine at Harvard Medical

School who has multiple sclerosis and uses a wheelchair, said she went 20 years without properly being weighed. This can result in treatment plans, and even prescriptions, based on educated guesses rather than exact information, she said. The Affordable Care Act was set to update standards for accessible medical treatment within the Americans with Disabilities Act (ADA), which is enforced by the Justice Department. But the Trump administration stopped action on this change late last year as

part of its sweeping effort to roll back regulations across the federal government. “I was in shock when I heard that [Attorney General Jeff] Sessions’ Justice Department had pulled back on their rule-making,” said Iezzoni. Denise Hok, 54, who lives in Colorado Springs, Colo., and uses a wheelchair, opts for home health care when possible and avoids doctors’ offices where “it feels like it doesn’t really matter if something is wrong.” When offices don’t have accessible equipment, she said, it “sends a message.”

The ADA, a 1990 civil rights measure designed to prohibit discrimination against people with disabilities, requires that public places be accessible, meaning new buildings and certain commercial establishments must provide ramps, doorways wide enough for a wheelchair, handrails and elevators. The law applies only to fixed structures, though, and doesn’t address “furnishings” unattached to buildings. At doctors’ offices, that means scales, tables, X-ray machines and other diagnostic equipment aren’t legally circumscribed….Read More

Providing Medicare Beneficiaries with Complete, Objective Information The Center for Medicare Advocacy and the National Committee to Preserve Social Security and Medicare have partnered to develop an education and outreach project to support Medicare beneficiaries and those who assist them enroll and re-enroll in Medicare. The Medicare Fully Informed Project provides a variety of unbiased, accurate and comprehensive information about the full range of Medicare coverage options, and includes an array of tools to assist in making the best individual enrollment choices. Making Medicare coverage decisions is a complex task with multiple personal factors that must be taken into account. Beneficiaries need help in understanding all their complex options including all the pros and cons of traditional Medicare and private Medicare Advantage. They need to make fully informed choices given their likely health needs, personal and financial circumstances, and possible cost-sharing assistance. Our organizations and other beneficiary advocates have been

concerned about the objectivity of some Centers for Medicare & Medicaid Services (CMS) enrollment materials. We hope to help fill some of the gaps. In preparing for this project, we polled over 2,000 members of the National Committee to Preserve Social Security and Medicare in August 2018 in order to better understand Medicare beneficiaries, their unique needs, Medicare choices, and how we can better serve them. The responses helped us identify knowledge gaps and develop the suite of materials developed for this project. Key survey results that informed this project include:  61% of respondents are in traditional Medicare  54% of respondents make enrollment decisions through on-line research  Half of all respondents said they want more information about their enrollment choices  77% receive the annual Medicare & You handbook from CMS

 Less than half of respondents comparison shop between Medicare Advantage and Part D prescription drug plans  Only 13% changed their Medicare Advantage plan or Part D plans in the last year  57% have one or more preexisting health condition  57% are not aware of Medicare’s Extra-Help program  Male respondents made up about 45%; female respondents comprised 54%  54% live in suburban areas while 25% live in rural areas and 20% in urban areas The results of the poll confirm that Medicare beneficiaries need additional, objective tools and information to make informed decisions about their Medicare options. They are also a diverse group who often face significant barriers when switching between plans or navigating these complex programs. The goal of the Medicare Fully Informed Project is to help

by providing a variety of educational tools for beneficiaries, and those who help beneficiaries, make enrollment decisions. We hope these various formats will help beneficiaries make fully informed Medicare and related health care coverage decisions. Project materials include the following links:  Medicare Advantage Brochure  Self-help Document – Choosing Between MA and Traditional Medicare  Decision Tree Infographic: Traditional Medicare or Medicare Advantage  Medicare & You Handbook – Key page corrections  Medigap – Supplemental Insurance to Help with Cost-Sharing in Traditional Medicare  Q&A Medicare Part D  Power Point Presentation: Choosing Between MA and Traditional Medicare (Depending on your settings, this will play in your browser or download for play)  Combined .pdf

Pre-Existing Conditions: Here’s What You Need to Know Pre-existing conditions have been prominent in the news lately and much of the discussion includes some misunderstandings about what it actually means to protect coverage of pre-existing conditions and why it matters. While Medicare and Medicaid cover pre-existing conditions and that coverage is not under threat, ther e ar e changes in laws and regulations, and even a pending court case, that do put coverage at risk for millions of people in the United States who are covered by employer or individual insurance. Polling consistently finds that Americans want protections for pre-existing conditions, with 75% of the public saying it’s “very important” such protections remain law. But ther e is a lot of confusion about what this means. Pre-existing conditions are health problems that a person has before they become insured by a particular insurer. For example, if a person who has asthma gets a new job with new health insurance, their asthma is a preexisting condition. Historically, insurers have chosen not to cover pre-existing conditions whenever

possible, but there are laws in effect that require insurers to cover them under most circumstances. Before the Affordable Care Act (ACA) was passed, individual plans often completely excluded coverage for pre-existing conditions, meaning the consumer could buy the insurance policy but would have coverage only for new conditions. Some insurers would cover pre-existing conditions but would charge exorbitant rates for the coverage. In other cases, the insurers refused to sell the policy at all to some consumers. For employer plans, most new employees faced waiting periods of up to a year before their preexisting conditions would be covered unless they were already insured. One of the strongest consumer protections from the ACA is the requirement that insurers cover pre-existing conditions in products sold to employers or the individual market without exclusions, waiting periods, price hikes, or denials. This opened up the insurance market to millions of people who could not get coverage before. In 2017, Congressional

Republicans and the Trump administration supported bills that would have repealed the ACA and eliminated these protections. Again, without the ACA in place, many people with preexisting conditions could not find coverage, either because they were rejected or because they could not afford the premiums. While those attempts to repeal the ACA in 2017 failed, there are now whispers that the effort is not yet dead and that Congress may return to repeal in 2019. Even without repeal, the Trump administration has taken many steps to decrease the protection of the ACA by expanding shortterm and association plan availability and, as of this week, providing federal funding to allow people to buy plans that do not cover preexisting conditions at all. In addition, the administration is supporting a lawsuit that would eradicate the ACA’s protections for pre-existing conditions entirely. Thr eats to this vital coverage are coming from all directions at once. Larry Levitt of the Kaiser

Family Foundation lays out important things to consider when health insurance claims to cover pre-existing conditions:  Does it guarantee access to coverage irrespective of health?  Does it require community rating, meaning the same premiums for people who are healthy and sick?  Does it mandate a package of required benefits?  Can insurers exclude coverage of preexisting conditions?  Are annual and lifetime limits on coverage allowed? Medicare, Medicaid, and ACA-compliant plans pass these tests but some of the new insurance offerings do not. It’s important that anyone in the market for new insurance understand how the plan works and what it might exclude. Read more about short-term and association plans. Read more about how the ACA changed employer coverage. Read more about what it means to protect pre-existing conditions.

How Prior Authorization Can Impede Access to Care in Medicare Advantage While Medicare Advantage (MA) plans are required to cover the same health services as Original Medicare, they are not required to offer the same level of provider access and can impose coverage restrictions— like prior authorization—that require enrollees to take additional steps before accessing prescribed care. If a service is covered “with prior authorization,” enrollees must get approval from the plan prior to receiving the service. If approval is not granted or sought, the plan generally will not cover it. A new analysis from the Kaiser Family Foundation looks

at the prevalence of prior authorization in MA and found that many plans utilize this flexibility: 80% of MA enrollees are in plans that require prior authorization for at least one Medicare-covered service. Original Medicare, in contrast, does not require prior authorization for the vast majority of services, making this an important distinction between the two coverage options. In some instances, prior authorization may be an appropriate utilization management tool. In particular this is true when both beneficiaries and providers are

likely to benefit from advance knowledge of Medicare coverage. However, MA’s broad application of prior authorization can impede access to care. On our National Helpline, we frequently hear from MA enrollees who are experiencing a range of denials for healthrelated services, and who are concerned and confused about their plan’s service denials and coverage requirements. While each MA plan has different rules, as the KFF report indicates, many require enrollees to obtain approval before

receiving an array of critical services:  At least 70% of enrollees are in plans that require prior authorization for Part B drugs and inpatient hospital stays.  60% of enrollees are in plans that require prior authorization for ambulance, home health, procedures, and laboratory tests.  More than half of enrollees are in plans that require prior authorization for mental health services….Read More

How States Have Tried To Close Their Pension Funding Gaps Teachers, firefighters, police and other government workers in states across America are facing a retirement crisis. Half of all states haven’t saved enough to pay the benefits they promised through public pensions. The bill — now in the trillions — is starting to come due. For more than a century, public workers accepted lower salaries on the promise of a safety net later in life. When their pension funds were flush with cash, some states cut back on payments. Then came the dot-com crash, the 2008 recession and state budget shortfalls, and those states suddenly found their pensions deep in the red. “The most common reason these things don’t turn out so well is because the state didn’t make the contributions,” said Richard Johnson, program director of retirement policy at the Urban Institute. States instead put that money into more immediate budget concerns, such as education, he said. As a result, some retirees are already seeing smaller monthly checks and current employees and new hires may see their pensions slashed further. Nationwide, public pensions are roughly 70 percent funded, falling below what national standards consider to be healthy. Only one state – Wisconsin – has a fully funded pension. “One of the reasons that we accept the low salary is that we won’t have to despair of our retirement,” Randy Wieck, a public school teacher in Kentucky, told FRONTLINE in The Pension Gamble. “It’s a promise and a good chunk of our salary is taken out from day one and deposited into a retirement plan.” Public pensions are about a third funded in Kentucky,

according to state annual reports in 2016 analyzed by Bloomberg — a yawning gap that led to large teacher protests in March 2018 and a controversial new pension law that is currently being challenged in the state supreme court. Kentucky is not alone: New Jersey, Illinois, and Connecticut are facing similar challenges, according to numbers by Pew and Bloomberg. Since the recession, states have been scrambling to fix the problem — mostly by passing the shortfall on to their employees. That usually means employees must contribute more toward their pensions and get fewer benefits. Since 2009, 35 states have passed legislation increasing what employees have to pay into their pension plan, according to research by the National Association of State Retirement Administrators, an organization that supports traditional pensions. This change affected both current and new employees in most situations. More than half the states in the U.S. now require people to work longer or retire later before they can claim their benefit. For example Colorado, which overhauled its pensions earlier this year, raised the retirement age for new hires after 2020 to 64 years, from 60 and 58 for state employees and teachers, respectively. Plans in several states have also reduced how much they pay in pensions by changing how the pension benefit is calculated. It’s more difficult to alter payouts for people who have already retired, since those benefits are usually legally protected. But some states have reduced what’s called the cost of living adjustment paid to

retirees, an annual increase that is supposed to shield payouts from inflation. In 2013, for example, Kentucky’s largest public pension plan, with more than 350,000 members, suspended all cost of living adjustments until the system is 100 percent funded — a date that’s still in question — or money is set aside by the state. At least 13 states have passed laws committing to bridging the financial gap. Some are taking creative approaches, like funneling earnings from cigarette taxes or state-owned casinos into their pension funds. In the past decade, government contributions to pensions have increased dramatically — by about 76 percent, according to the Urban Institute’s Johnson, who made the calculation based on census data. Oregon, for example, passed a law in 2018 that earmarked taxes on alcohol and marijuana and lottery revenues, among other things, to help bankroll pensions. Last year, New Jersey dedicated all earnings from the state lottery to the public pension fund, a move that will generate $1 billion per year, according to a recent report by the state’s independent pensions commission. A handful of states have moved away from the traditional pension model altogether, toward a 401(k)-style plan. States find such models attractive because it can be cheaper. They contribute less toward an employee’s retirement fund, and the financial risk is also passed to the employee in a 401(k) plan — as are the investment decisions. For employees, the plans have no guarantee: a

person can save up a lifetime of earnings for retirement, only to lose it all in a stock market crash. The few states that have experimented with the switch have faced considerable backlash from public sector employees. When the Oklahoma governor pushed for a 401(k) pension plan in 2014, hundreds of teachers, firefighters, and other state employees took to the streets to rally against the proposed changes. Ultimately, new state employees would be moved to a 401(k) plan after November 2015. After Alaska switched to a 401(k) system in 2005, the state’s public safety department said in recent report that prospective employees found jobs in other states more attractive because of the retirement benefits. “In Alaska, for example, one of the things they found is they cannot recruit and retain public safety officers,” Diane Oakley, executive director of the propension National Institute on Retirement Security, told FRONTLINE. “So, there’s almost a dozen trooper cars sitting outside the headquarters, with no trooper to fill them.” However, for the states that have the biggest funding gaps in their pension plans, the risk isn’t just that they’ll lose employees. “Long term, the biggest risk is to future taxpayers,” said Johnson. “They’re the ones who are either going to have to pay higher taxes… or going to have to accept fewer services, because a bigger share of their tax money will have to go to close this funding gap.”

Watch the Film The Pension Gamble

That’s A Lot Of Scratch: The $48,329 Allergy Test Janet Winston had a rash that wouldn’t go away. The English professor from Eureka, Calif., always had been sensitive to ingredients in skin creams and cosmetics. This time, however, the antifungal cream she was prescribed to treat her persistent rash seemed to make things worse. Was she allergic to that, too? Do you have an exorbitant or baffling medical bill? Join the KHN and NPR’s Bill-of-theMonth Club and tell us about your experience. We’ll feature a new one each month. Winston, 56, who works at Humboldt State University, knew the dermatologist in her rural Northern California town was booked months in advance. So, as she often does for specialized treatment, she turned

to Stanford Health Care, a nearly six-hour drive south. She hoped to finally clear up her rash and learn what else she might be allergic to — for years, she had avoided lipstick and other skin products. Winston said that 119 tiny plastic containers of allergens were taped to her back over three days of testing. Winston ultimately learned that she was allergic to — among other things — linalool (a compound of lavender and other plants), the metals gold, nickel and cobalt, the ketoconazole cream prescribed to treat her persistent rash, the antibiotic neomycin, a

clothing dye, and a common preservative used in cosmetics. Her Stanfordaffiliated doctor had warned her that the extensive allergy skinpatch testing she needed might be expensive, Winston said, but she wasn’t too worried. After all, Stanford was an in-network provider for her insurer — and her insurance, one of her benefits as an employee of the state of California, always had been reliable. Then the bill came. Patient: Janet Winston, 56, of Eureka, Calif., English professor at Humboldt State University Total Bill: $48,329, including $848 for the time Winston spent

with her doctor. Winston’s health insurer, Anthem Blue Cross, paid Stanford a negotiated rate of $11,376.47. Stanford billed Winston $3,103.73 as her 20 percent share of the negotiated rate. Service Provider: Dr . Golara Honari of Stanford Health Care’s outpatient dermatology clinic in Redwood City, Calif. Medical Procedures: Extensive allergy skin-patch testing to determine what substances caused Winston’s contact dermatitis, or skin rashes. “I was grateful I had such wonderful care at Stanford,” Winston said, “but I was pretty outraged they could charge that. … No one cut into me. No one gave me anesthesia. I had partly open plastic containers filled with fluid taped to my back.” …..Read More One of the biggest reasons our health care is so expensive.

Dan Rather: I Do Not Think President Trump Is Redeemable There is no middle ground on hate. There are no ends justifying the means. No tax cuts. No deregulation. No scores of conservative judges can be worth tearing asunder the foundation of American freedom and democracy. And yet we now stand on that precipice I do not think President Trump is redeemable on this score. His actions long before becoming president suggest a profound level of personal animosity to the diversity of our nation. And now, drunk on power and exalting in the amen choruses assembling at his hatefilled rallies, his debasement of the norms of the office he holds and his misplaced sense of victimhood has metastasized across a political movement that

has become increasingly indistinguishable from the political party he leads. We must find other pressure points to return the United States to a path of sanity. One big moment is the upcoming election. Americans must vote with the message of “This will not be us!” And they must not tremble in the face of voter intimidation and threats of violence. I believe that most Americans recoil from the hate and injustice. That’s why GOP officials are lying about their records on health care. They are playing a cynical game of stoking their restive minority through propaganda and lies

while intimidating and demoralizing the majority. That’s why they seek to distract with all this gunned-up racism and antiSemitism. Republican officials who play in cynical games of wink, nod, abet, and excuse must hear loud and clear that their complicity is akin to an endorsement. This can be a delicate balance. One can understand that words and actions are different and that one cannot be held accountable for the actions of a deranged loner. But one can be held accountable for stoking a climate where these actions burst forth with the frequency and seriousness we are

witnessing. Where we used to speak of dog whistles we now hear bullhorns. There is nothing subtle or hidden about what’s going on. And no one can be allowed to pretend that this is just a slightly adulterated version of politicos as usual. All who support the president must be called to account for the hate they have allowed him to wreak upon this nation. This hate is bigger than Trump and it long preceded him. To personalize it around him is to excuse far too many for their tacit complicity. We are long beyond the stage of words of disapproval. We must dismantle the scaffolding that has allowed this terror to flourish.

RI ARA HealthLink Wellness News

Questions to Ask When a Loved One Is Diagnosed with Alzheimer’s or Dementia Find out as much as you can about your loved one’s current situation and expected trajectory of cognitive decline. IT STARTS OUT SLOWLY, almost imperceptibly. The misplaced keys. The forgotten birthday or anniversary. Using the wrong word or losing the thread in mid-conversation. These are often dismissed as

typical signs of aging, but in some people, they may be the earliest signs that something bigger is at work – the development of dementia or Alzheimer's disease. When a doctor diagnoses dementia or Alzheimer's in your loved one, you should be sure to ask a lot of questions to make

sure you understand progress? your loved one's 4. Does my loved one current state of being understand what's going and so you can on? appropriately prepare 5. What do I, as a caregiver, for how this progressive disease need to know? could change over time. 6. What should my next steps 1. Is it Alzheimer's or another be? kind of dementia? Read More on these 6 questions. 2. What else could it be? 3. How will the disease

The signs and symptoms of Parkinson's disease Parkinson's disease is a neurological condition with a wide range of effects, including problems with movement, blood pressure and thinking, and mood, sensory, and sleep difficulties. The symptoms of Parkinson's disease (PD) usually begin gradually, and they affect each person differently. The symptoms a person has will vary widely, regardless of how severe they are or how quickly they develop. Read on to find out more about the different types of symptoms and how to recognize the early symptoms of PD. Early symptoms The symptoms of PD affect individuals differently, but some can be an early sign of the disease. These are:  REM sleep disorder and other sleep problems  the loss of the sense of smell  tremor, especially in one hand  a smaller size of handwriting  difficulty moving or walking or a stooping gait  constipation  loss of facial expression, that may make the person look emotionless  a low or soft voice Primary motor symptoms The four main signs and symptoms include:  slow physical movements, known as bradykinesia

 shaking, or tremor  muscle stiffness, or rigidity  problems with balance and coordination, known as postural instability Symptoms often start on one side first. Slow physical movement The person finds it hard to start moving. Starting to get up from a chair can become more difficult, for example. It takes longer than before to do physical tasks. A lack of coordination can cause the person to fall or drop things. The difficulty is not only with carrying out the movement itself, but also with planning and starting it. Many people may experience slower movements and attribute these to older age, but sometimes they are a sign of PD. Slow physical movement The person finds it hard to start moving. Starting to get up from a chair can become more difficult, for example. It takes longer than before to do physical tasks. A lack of coordination can cause the person to fall or drop things. The difficulty is not only with carrying out the movement itself, but also with planning and starting it. Many people may experience slower movements and attribute these to older age, but sometimes they are a sign of PD.

Tremor As the person experiences changes in their posture, coordination, and ability to move, falls can become more likely. Tremor is a familiar symptom of PD to many people. The shaking often starts in one hand. It may start in one foot, or the person may begin rubbing their forefinger and thumb together, back-and-forth. Less commonly, it starts in the jaw or face. Many people do not have a severe tremor. It is usually more likely to happen when the affected part of the body is resting. Stress or anxiety may make it more noticeable. Other conditions that may lead to tremor include:  multiple sclerosis  encephalitis, an inflammation of the brain alcohol use disorder The presence of tremor is not necessarily a sign of PD. However, according to the Parkinson's Disease Foundation, around 70 percent of people with PD experience a slight tremor at some time during the disease. Secondary motor symptoms In addition to the primary motor symptoms, a person may also:  stoop or lean forward, as if

they are walking quickly

 walk with the arms held stiffly by their side  experience muscle cramps  experience drool  feel tired  write with a small, cramped hand  have difficulty with fine finger movements  have difficulty coordinating movements  make involuntary movements and have prolonged muscle contractions  lose facial expression, which can make the person appear uninterested when speaking or cause them to stare fixedly with unblinking eyes  experience sexual dysfunction  speak more softly, slur or repeat words, use a monotonous voice, or speak with varying speeds, either faster or more slowly  have difficulty swallowing  not swing the arms when walking Rigidity The muscles feel stiff, and this can make some everyday tasks troublesome, such as getting out of a chair, rolling over in bed, using body language appropriately, or making fine finger movements. ….Read More

What are the risk factors for Parkinson's disease? People do not know exactly what causes Parkinson's disease, but there is evidence that certain factors may make it more likely to occur. Read on to find out more about genetic factors and environmental exposures that might make Parkinson's disease (PD) more likely to appear in some people. Some of these are unavoidable, but for others, early lifestyle choices and caution may help reduce the risk. Age and sex Two unavoidable factors that affect the risk of having PD are increasing age and whether a person is male or female. Age: In most people who have PD, symptoms become noticeable at the age of 60 years or over. However, in 5–10 percent of cases they appear earlier. When

PD develops before the age of 50 years, this is called "early onset" PD. Sex: Men appear to have a 50-percent higher chance of developing PD than women. However, at least one study has found that, as women get older, their chance of developing it increases. Researchers have suggested that this could be due to a variety of factors, including:  lifestyle exposures  genetic features  hormonal and reproductive factors  differences in the brain structures that relate to the production of dopamine Genetic factors and family history  A person who has a close relative — such as a sibling or parent — with PD has a

slightly higher risk of changes occur in two copies developing it, of a certain gene, PD can compared with others. occur. These changes may involve the genes known as  According to the PARK7, PINK1, and PRKN. Parkinson's Foundation, around 10 to 15  Risk-factor modifier genes: percent of cases are probably These genes affect the risk of due to hereditary genetic developing PD, but they do factors. not cause symptoms. The gene known as GBA is one of  The others are "sporadic." these. This gene makes the There is currently no way to enzyme glucocerebrosidase. predict that they will occur.  Autosomal dominant: In 1 to  Not everyone with a gene mutation will develop PD. 2 percent of people with PD, Some people with a family the condition results from a history of PD choose to change in just one copy of a undergo genetic testing to specific gene. Genes that it have some idea of how likely can affect include Alphathey are to have this problem. synuclein (SNCA) and leucine-rich repeat kinase 2  This can be useful to know, (LRRK2). but it is not always a good idea. Some people have a  According to the Parkinson's genetic factor but never Foundation, men of Northdevelop PD. This can lead to African Arab origin have a unnecessary anxiety...Read higher chance of having this More trait.  Autosomal recessive: If

Treatment options for Parkinson's disease Parkinson's disease is a complex condition with a wide range of symptoms. There is currently no cure, but treatment can help relieve symptoms, slow disease progression, and improve quality of life. Treatment approaches include medication, surgery, alternative and complementary therapies, occupational therapy, and speech therapy. The symptoms of Parkinson's disease (PD) vary widely so no single treatment will work for everyone with this condition. Medication The National Institutes of Health note that there are three types of drug available to treat PD:  medications that raise dopamine levels in the brain, such as levodopa (also known as L-dopa), and drugs that mimic dopamine or stop it from breaking down  drugs that reduce or relieve

tremor, or shaking, and other symptoms affecting body movements  medication for depression, psychosis, de mentia, and other non-motor symptoms Increasing dopamine levels The symptoms of PD are mainly due to low levels of dopamine in the brain. Dopamine is a chemical messenger, or neurotransmitter. Most drugs for the condition aim to either replenish dopamine levels or mimic its action. These are called dopaminergic drugs. Dopaminergic medications can:  reduce rigidity and muscle stiffness  improve the speed of movement  help with coordination  lessen tremor Taking dopamine itself does not help because it cannot enter

the brain, but drugs that enable the brain to create dopamine can be beneficial. Doctors may prescribe the following medications for people with PD:  Levodopa  Carbidopa-levodopa  Dopamine agonists  Monoamine oxidase-B inhibitors (MAO-B inhibitors)  Catechol Omethyltransferase (COMT) inhibitors  Anticholinergics Depression, psychosis, and dementia Depression is a common problem for people with PD. The American Academy of Neurology (AAN) recommend amitriptyline for treating depression, stating that there is currently insufficient evidence to

support the use of other treatments. Psychosis can also occur, and this becomes more severe as the disease progresses. Clozapine (Clozaril) can treat psychosis, but doctors should monitor the person carefully as this medication can have severe adverse effects. Dementia develops over time in many people with PD, especially if they have PD with Lewy bodies. Lewy bodies are abnormal deposits in the brain. Rivastigmine (Exelon) is a treatment option for dementia, but the AAN point out that the benefits can be small, and it may make tremors worse. Donepezil (Aricept) is another option. Click here to read more on treatments for this very debilitating disease.