You were conceived by Senator and then-President John F. Kennedy and born on July 30, 1965, when President Lyndon Johnson signed the law after a contentious debate in Congress.

Has it worked, or does it need to be improved? In every poll taken, people “love” their Medicare and don’t want it taken away.

But let’s look at the data. Only 50 percent of individuals over 65 years old had health insurance in 1965. Now 98 percent do.

Medicare insures 60,000 individuals in Sonoma County, 4.5 million in California and 53.5 million in the United States. In one attempt to improve it, in 1972 Medicare added adults who had been disabled for two years and patients with end-stage renal disease on dialysis. Eighty-five percent of Medicare recipients in Sonoma County are over 65 years old, 14 percent are disabled adults, and 1 percent have ESRD.

But Medicare is actually still very expensive for individuals. In 2013 Medicare spent $11,320/enrollee in California ($600 above the national average). Of this total individuals paid an average of $1,336 out-of-pocket, some as high as $2,500. In Sonoma County 67 percent of those on Medicare live on less than $35,000 and 54 percent less than $25,000. Medicare has drastically reduced but not eliminated the number of individual bankruptcies due to medical debt.

Nationally, Medicare covers only 50 percent of medical costs.

In another attempt to improve Medicare, in 2003 optional drug coverage (Part D) was added as a benefit, and more than 70 percent of Medicare enrollees participate in Part D. But, also in 2003, as part of that legislation, Congress prohibited Medicare from negotiating lower drug prices (and individuals from buying drugs in other countries with lower prices), resulting in drug prices 40 to 50 percent higher in the U.S.

Yet, despite providing a wide range of benefits, the overhead of Medicare — always low — in the past three years has been less than 2 percent. Compare this to the 10 to 20 percent of most private insurance companies.

It was envisioned, in 1965 when Medicare was passed, that Medicare would eventually be expanded to include all age groups and all people living in the United States.

However, ideological differences and political divisions have impeded that reality. The Affordable Care Act (passed in 2010) is an attempt to expand health care coverage, but it will still leave 30 million uninsured when fully-implemented and is unlikely to control rising health care costs.

How can we really improve Medicare? How can we live up to the original vision?

A bill currently in Congress (HR 676) proposes “improved and expanded Medicare for all.” This would expand Medicare to all those living in the U.S. and would provide — in addition to all inpatient, outpatient, emergency room, drug coverage, mental health, and physical therapy services — drug and alcohol rehabilitation, vision care, dental care, and long-term care.

All of this would be without co-pays, co-insurance, or deductibles. How would this be possible? Because such a program would negotiate for lower drug and medical device charges, require hospitals to be nonprofit, and eliminate $400 billion/year in unnecessary overhead and profits in the current multi-payer system.

As Martin Luther King, Jr., said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Dr. Nick Anton practiced internal medicine in Santa Rosa for 34 years before retiring in 2009. He is a member of Physicians for a National Health Program.

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There’s a plot, familiar to adventure film fans, in which the hero must keep moving or die.

Although the average person’s situation isn’t that dramatic, a lack of movement could be detrimental.

“Prolonged sitting slows down the metabolism regardless of fitness levels,” writes Arto Pesola, exercise physiologist, in an email interview.

That phrase “regardless of fitness levels” is important.

You can’t lull yourself into thinking you’re doing enough if you only follow the current guidelines to get at least 150 minutes of physical activity a week, health experts say.

You’re still coming up short.

That 150 minutes a week is only about 2 percent of the time you're awake during the week, and it isn't enough to go to the gym three times a week, says Dr. Srinivasan Beddhu, professor of medicine at the University of Utah School of Medicine, Salt Lake City.

Instead, more consistent and frequent effort is needed.

But unlike those movies in which characters are running through the streets, you can take a moderate approach.

If you simply switch out two minutes of sitting time every waking hour for light intensity exercise, such as walking, you may strengthen your heart, muscles and bones and significantly reduce your risk of early death, according to a recent study in the Clinical Journal of the American Society of Nephrology.

Frequent exercise throughout the day is important to counter the negative effects of prolonged sitting, according to Pesola.

“Prolonged sitting slows down the metabolism, regardless of fitness levels,” writes Pesola, Ph.D. candidate, department of biology of physical activity, University of Jyvaskyla, Finland.

“For example, the activity of 'fat-burning enzymes' drops and the insulin sensitivity decreases during periods when there’s no activity in muscles and the whole body energy expenditure is low,” he writes.

Simply standing up from a chair increases energy expenditure by 15 to 20 percent, and thigh muscle activity by 200 percent, according to Pesola, whose study showing that muscle inactivity is adversely associated with (health) biomarkers was published in Medicine & Science in Sports & Exercise, the journal of the American College of Sports Medicine.

If the act of getting up is so beneficial, how about spending more time standing?

It’s not enough, according to Dr. Beddhu.

Although standing may have health advantages when compared with sitting, that trade-off doesn’t provide a mortality benefit, according to Dr. Beddhu, who looked at activity and health for the study in the nephrology journal.

“On the other hand, if you trade sitting time for casual walking time there’s a mortality benefit,” Dr. Beddhu says.

His study looked at physical activity and mortality from more than 3,000 participants in the National Health and Nutrition Examination Survey (NHANES).

Increased light intensity activity was associated with a 33 percent lower risk of dying, according to the nephrology journal study.

Dr. Beddhu recommends taking a two-minute or longer exercise break every hour you’re awake.

You can do this by walking during television commercials or telephone conversations or making frequent visits to other parts of your office building.

Those minutes add up.

Assuming you’re awake 16 hours a day, that’s 32 more minutes of physical activity a day.

“It’s two minutes on top of what you’re already doing. If you can do five minutes per hour, even better,” says Dr. Beddhu, who also recommends adding in moderate exercise for cardiovascular health. 

...

There’s a plot, familiar to adventure film fans, in which the hero must keep moving or die.

Although the average person’s situation isn’t that dramatic, a lack of movement could be detrimental.

“Prolonged sitting slows down the metabolism regardless of fitness levels,” writes Arto Pesola, exercise physiologist, in an email interview.

That phrase “regardless of fitness levels” is important.

You can’t lull yourself into thinking you’re doing enough if you only follow the current guidelines to get at least 150 minutes of physical activity a week, health experts say.

You’re still coming up short.

That 150 minutes a week is only about 2 percent of the time you're awake during the week, and it isn't enough to go to the gym three times a week, says Dr. Srinivasan Beddhu, professor of medicine at the University of Utah School of Medicine, Salt Lake City.

Instead, more consistent and frequent effort is needed.

But unlike those movies in which characters are running through the streets, you can take a moderate approach.

If you simply switch out two minutes of sitting time every waking hour for light intensity exercise, such as walking, you may strengthen your heart, muscles and bones and significantly reduce your risk of early death, according to a recent study in the Clinical Journal of the American Society of Nephrology.

Frequent exercise throughout the day is important to counter the negative effects of prolonged sitting, according to Pesola.

“Prolonged sitting slows down the metabolism, regardless of fitness levels,” writes Pesola, Ph.D. candidate, department of biology of physical activity, University of Jyvaskyla, Finland.

“For example, the activity of 'fat-burning enzymes' drops and the insulin sensitivity decreases during periods when there’s no activity in muscles and the whole body energy expenditure is low,” he writes.

Simply standing up from a chair increases energy expenditure by 15 to 20 percent, and thigh muscle activity by 200 percent, according to Pesola, whose study showing that muscle inactivity is adversely associated with (health) biomarkers was published in Medicine & Science in Sports & Exercise, the journal of the American College of Sports Medicine.

If the act of getting up is so beneficial, how about spending more time standing?

It’s not enough, according to Dr. Beddhu.

Although standing may have health advantages when compared with sitting, that trade-off doesn’t provide a mortality benefit, according to Dr. Beddhu, who looked at activity and health for the study in the nephrology journal.

“On the other hand, if you trade sitting time for casual walking time there’s a mortality benefit,” Dr. Beddhu says.

His study looked at physical activity and mortality from more than 3,000 participants in the National Health and Nutrition Examination Survey (NHANES).

Increased light intensity activity was associated with a 33 percent lower risk of dying, according to the nephrology journal study.

Dr. Beddhu recommends taking a two-minute or longer exercise break every hour you’re awake.

You can do this by walking during television commercials or telephone conversations or making frequent visits to other parts of your office building.

Those minutes add up.

Assuming you’re awake 16 hours a day, that’s 32 more minutes of physical activity a day.

“It’s two minutes on top of what you’re already doing. If you can do five minutes per hour, even better,” says Dr. Beddhu, who also recommends adding in moderate exercise for cardiovascular health. 

...

INTRODUCTION: The proportion of patients with stage 1 renal tumours receiving partial nephrectomy is considered a quality of care indicator. The objective of this study was to characterize surgical practice patterns at Canadian academic institutions for the treatment of these tumours.

METHODS: The Canadian Kidney Cancer Information System (CKCis) is a multicentre collaboration of 13 academic institutions in Canada. All patients with pathologic stage T1 renal tumours in CKCis were identified. Descriptive statistics were performed to characterize practice patterns over time. Associations between patient, tumour, and treatment factors with the use of partial nephrectomy were determined.

RESULTS: From 1988 to April 2014, 1453 patients with pathologic stage 1 renal tumours were entered in the CKCis database. Of these, 977 (67%) patients had pT1a tumours; of these, 765 (78%) received partial nephrectomy. Of the total number of patients (1453), 476 (33%) had pT1b tumours; of these, 204 (43%) received partial nephrectomy. The use of partial nephrectomy increased over time from 60% to 90% for pT1a tumours and 20% to 60% for pT1b tumours. Stage pT1b (relative risk [RR] 0.56, 95% confidence interval [CI] 0.50-0.63) and minimally invasive surgical approach (RR 0.78, 95% CI 0.73-0.84 for pT1a and RR 0.23, 95% CI 0.17-0.30 for pT1b) were associated with decreased use of partial nephrectomy. Most patient factors including age, gender, body mass index, hypertension, and renal function were not significantly associated with use of partial nephrectomy (p > 0.05).

CONCLUSIONS: Almost all pT1a and most pT1b renal tumours managed surgically at academic centres in Canada receive partial nephrectomy. The use of partial versus radical nephrectomy appears to occur independently of patient age and comorbid status, which may indicate that urologists are performing partial nephrectomy whenever technically feasible based on tumour factors. Although the ideal proportion patients receiving partial nephrectomy cannot be determined, treatment distribution observed in this cohort may indicate an achievable case distribution among experienced surgeons.

Can Urol Assoc J. 2015 Mar-Apr;9(3-4):99-106. doi: 10.5489/cuaj.2598 

Lavallée LT1, Tanguay S2, Jewett MA3, Wood L4, Kapoor A5, Rendon RA6, Moore RB7, Lacombe L8, Kawakami J9, Pautler SE10, Drachenberg DE11, Black PC12, Lattouf JB13, Morash C14, Cagiannos I14, Liu Z15, Breau RH1.

1 Division of Urology, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON;

2 Division of Urology, McGill University, Montreal, QC;

3 Division of Urology, University of Toronto, Toronto, ON;

4 Department of Medicine and Urology, Dalhousie University, Halifax, NS;

5 Division of Urology, McMaster University, Hamilton, ON;

6 Department of Urology, Dalhousie University, Halifax, NS;

7 Division of Urology, University of Alberta, Edmonton, AB;

8 Division of Urology, Université Laval, Quebec City, QC;

9 Division of Urology, University of Calgary, Calgary, AB;

10 Division of Urology, Western University, London, ON;

11 Division of Urology, University of Manitoba, Winnipeg, MB;

12 Department of Urologic Sciences, University of British Columbia, Vancouver, BC;

13 Division of Urology, Centre hospitalier de l'université de Montreal, Montreal, QC;

14 Division of Urology, University of Ottawa, Ottawa, ON;

15 Cancer Care Ontario, Toronto, Ontario, Canada.

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