TIME Healthcare

Hospitals Have Reduced Deaths, Hospitalizations, and Costs Among Medicare Patients

"It's a jaw-dropping finding"

American hospitals have reduced deaths, hospitalizations, and costs among people over the age of 65 in the past couple of decades, according to a new report released Tuesday.

“We didn’t expect to see such a remarkable improvement over time,” said Harlan Krumholz, a cardiologist at the Yale School of Medicine and lead author of the study, which appeared in the Journal of the American Medical Association (JAMA).

Krumholz and his colleagues looked at over 68 million Medicare beneficiaries between 1999 and 2013. The group was chosen for their “fee-for-service” structure, where doctors and hospitals would be paid per procedure or visit.

They found that hospitalization rates for this group plummeted 24%, saving more than 3 million people unnecessary hospital visits. Their chance of survival and recovery had improved from less than two decades ago: patients were 45% less likely to die during their stay, 24% less likely to die within a month of being admitted, and 22% less likely to die within the year.

Deaths among the group fell 16%, meaning 300,000 lives were saved in the 14-year span, according to the report. Patients who visited the hospital also saw a 15% drop in their bills compared to 1999.

Krumholz said that better training for hospital staff led to many of the improvements.

“There has been tremendous focus on making sure that our hospitals are safer and that treatments are more timely and effective,” Krumholz told USA Today.

People are also living healthier, longer lives—smoking less, breathing cleaner air, and able to take advantage of scientific breakthroughs in medicine.

Despite doing so well, Krumholz doesn’t think it’s time for hospitals to get lax.

“The things we’re trying to do to make things better are working,” Krumholz noted. “Rather than wave the victory flag, we want to see that trend continue. There’s no reason to take our foot off the pedal.”

 

TIME Healthcare

15 Weird Risk Factors for Kidney Stones

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Your love for leafy greens may increase risk for kidney stones

Anyone who’s ever passed a kidney stone before has probably wondered how something so small (usually, anyway!) can cause so much pain. Unfair, we know. About 1 in 11 people will suffer from a kidney stone in their lifetime—and once you’ve already had one, you’re about 50% more likely to have another. More bad news: At one time, stones primarily affected men, but new research shows that this gender gap has almost closed, possibly due to the rise in obesity.

What are kidney stones, exactly?

Most kidney stones are a solid mass of minerals that have congealed and lodged itself somewhere in your urinary tract. The majority of them are made of calcium—usually a combination of calcium and oxalate, but, in rarer cases, calcium and phosphate—and, to a much lesser extent, uric acid.

Now for the good news: With a few dietary and lifestyle tweaks, you might be able to slash your odds of ever suffering from a kidney stone again—or, even better, prevent one entirely.

Too little calcium

Since calcium is present in most kidney stones, it makes sense to just cut the nutrient right out of your diet, right? Nope. That was the old thinking. Now experts know that people who consume more calcium are less likely to encounter a kidney stone than those on low-calcium diets, according to one 2013 study by researchers from Harvard Medical School. “It’s all about balance,” says Mantu Gupta, MD, the chair of urology at Mount Sinai Roosevelt and Mount Sinai St. Luke’s Hospital. Dr. Gupta goes on to explain that if your diet is deficient in calcium, chemicals called oxalates, which normally bind to calcium in the digestive tract, will instead bind with calcium in the urine and trigger the formation of stones.

Your salad obsession

You eat all the right things, only to end up in a urologist’s office. What gives? Oxalates, again. These substances are found in leafy greens like spinach, rhubarb, and beets. Ideally, those oxalates will bind with calcium in your intestine and be shuttled out of your body via your urinary tract, says Roger L. Sur, MD, director of the University of California San Diego’s Comprehensive Kidney Stone Center. But when the amount of oxalates is too high, these chemicals can concentrate in the urine and lead to a stone formation. That’s not to say you should give up veggies, of course. Talk to your doctor about possible food swaps for lower-oxalate foods—for example, kale instead of spinach or cauliflower in place of amaranth.

A salty diet

Out of all the potential problems caused by too much salt, kidney stones are probably last on the list. But when your sodium intake rises, that can also trigger an increase in the amount of calcium your kidneys excrete. Translation: A build-up of calcium in the urine, which increases the risk of kidney stone formation, says Brian Stork, MD, a urologist and spokesperson for the American Urological Association. Experts recommend that most people limit their sodium consumption to 2,300 milligrams per day, but other people, like those with high blood pressure, should lower that to less than 1,500 milligrams per day.

Not enough citrus fruits

If you can’t remember the last time you had a lemon or grapefruit, consider this a reason to up your intake: Citrus fruits contain a compound called citrate, which is thought to help lower the risk of some kidney stones, says Dr. Gupta. Plus, one study in the journal Nature found that when people who normally avoided produce added fruits and vegetables into their diet for one month, they decreased the amount of kidney-stone-causing chemicals that were present in their urine. Try adding a lemon or lime wedge to your water daily, says Dr. Gupta.

Too much meat

On the other hand, eating too much poultry and red meat can also put you at risk for stones: One 2014 study in the journal Nutritional Epidemiology found that vegetarians and fish-eaters were 30 to 50% less likely to have kidney stones than people who ate about 100 grams of meat per day (think: a steak and a half). People who load up on meat might be crowding out fruits and vegetables from their diets—a mistake, since produce contains magnesium, which can also prevent stones from forming.

Living in the South

The Southeastern United States might be known as the Bible Belt, but urologists have another name for it: the kidney stone belt. One oft-cited study published in the American Journal of Epidemiology in 1996 found that people living in this area had nearly double the risk of stones as people living in cooler regions of the United States. Blame the hot, arid climate: “Because the temperatures are higher, people in the South can lose more fluid through sweat and become dehydrated,” says Dr. Gupta. When you aren’t drinking enough water, there will be a higher percentage of minerals in a lower amount of urine, increasing the likelihood that those minerals will bind together to form a stone.

Too much iced tea

Another strike against the sweet-tea-loving South. A 2015 report in the New England Journal of Medicine about a 56-year-old man who was rushed to the hospital for kidney failure after drinking too much iced tea shocked the Internet. And as it turned out, black tea (one of the most popular kinds in the U.S.) is also a major source of oxalate, which can cluster in the urine to form kidney stones. This man was drinking about 16 8-ounce glasses of black tea daily, which is at least double the average person’s daily intake. If you’ve had a kidney stone before, ask your doctor about limiting your consumption to one 8-ounce serving a day, says Dr. Gupta, who also notes that people with super high levels may have to cut it out of their diet completely.

A can of soda

Normally, staying hydrated is one of the smartest ways to avoid kidney stones because it dilutes kidney-stone forming substances: (That’s why experts say that drinking about eight glasses of water a day is one way to prevent them from forming in the first place.) But not all beverages are created equal: One 2013 study found that downing even one sugary-sweet soda a day can increase your odds of developing kidney stones by 23%. Researchers think that the fructose (a sugar) in sweetened drinks causes an increase in kidney stone-causing chemicals. Stick to water, minus the sugar.

Your parents

Here’s something else to thank mom and dad for: If either parent has had a kidney stone, your risk increases as well. Sure, families have similar diets, but there’s a biological reason as well. “Like obesity or diabetes, there are multiple genes involved, and oftentimes, people inherit the inability to efficiently absorb oxalate from their parents,” says Dr. Gupta.

Having IBD

People with inflammatory bowel diseases tend to have a higher risk for stones than those without these serious conditions, and one 2013 study in the International Journal of Nephrology and Renovascular Disease found that those with Crohn’s disease and ulcerative colitis were especially at risk. One reason: These conditions are accompanied by diarrhea, which can increase a person’s risk of dehydration—and, in turn, up the percentage of kidney stone-causing chemicals in lower amounts of urine, says Dr. Stork.

Recurring urinary tract infections

In this case, frequent UTIs are a possible sign of a kidney stone. Some background: Not all stones cause pain—in fact, some can pass through your body unnoticed. But other times, kidney stones stay in your urinary tract and block the flow of urine, which could lead to a UTI. This infection is one possible sign that you may have a kidney stone that you don’t know about, explains Dr. Sur. “In some people, the only way we would have found their kidney stones is because they had recurrent urinary tract infections,” he says.

Using too many laxatives

Laxatives have existed for over 2,000 years, and people have been abusing or misusing them that entire time, according to a 2010 study published in the journal Drugs. Older people dealing with constipation who believe they need to have a bowel movement daily for good health comprise a significant number of laxative abusers, but the largest group, by far, is made up of people suffering from anorexia or bulimia. Laxative overuse may interfere with your body’s ability to absorb nutrients and medications, and may also bring on an electrolyte imbalance—and it’s been linked to kidney stones, says Dr. Sur. Using too much of these meds may cause people to become dehydrated, which could trigger a stone.

A migraine medication

People who take topiramate (found in the prescription med called Topamax) can be more likely to have kidney stones than those who don’t take this drug, says Dr. Sur. One 2006 study in the American Journal of Kidney Diseases found that topiramate can increase the pH levels in the urinary tract, which may lead to an increased risk of kidney stone formation. (Talk to your doctor before making any changes to your medication regimen.)

Your weight

Obese women may be about 35% more likely to develop kidney stones than their leaner counterparts, according to a 2011 study in The Journal of Urology. Researchers aren’t quite sure why, but they suspect that the extra poundage changes the environment in your urinary tract, making it easier for kidney stones to form. “People who are obese have altered urinary pH levels, which can cause a buildup of uric acid-forming kidney stones,” says Dr. Sur.

Weight loss surgery

While it’s true that obesity increases your risk of stones, so can bariatric surgery, according to one 2009 study in The Journal of Urology. “It’s thought that after the procedure, people might not absorb as much calcium from their diets,” says Dr. Stork. “When that happens, the build-up of oxalate in the urinary tract could lead to a kidney stone.” If you’ve recently had surgery, talk to your doctor about how you can cut your risk, either by drinking more water, limiting meat and sodium, or consuming enough calcium.

This article originally appeared on Health.com

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6 Things Every Woman Should Know About Yeast Infections

So-called 'preventative' products may cause more harm than good

Sorry to be a downer, but if you haven’t had a yeast infection yet, you’ll probably get one eventually. Three out of four women will experience one sometime in her life—and half will have two or more. “These are so common because yeast normally lives on your skin and around your vagina,” says Melissa Goist, MD, an ob-gyn at The Ohio State University Wexner Medical Center. When something disrupts the vagina’s natural balance of healthy bacteria, yeast (aka the fungus Candida) can grow out of control. And then comes the telltale down-there itching and burning sensation that can drive you up a wall.

Whether you’ve been visited by a yeast problem once, a bunch of times, or not yet, you may be surprised by the truth about these frustrating infections. Here are the facts every woman should know.

The symptoms can mimic other problems

One study found that as few as 11% of women who have never had a yeast infection could identify the symptoms, while other research has found that only one-third of women who thought they had a yeast infection actually did. Why the confusion?

The signs are similar to other down-there problems. If you have a yeast infection, you might notice burning, itching, pain during sex, and a thick white odorless discharge.

But if it smells fishy, it may instead be bacterial vaginosis (BV), and if you have only burning and pain during urination, that suggests a urinary tract infection. Bottom line: It can be difficult to figure out.

First-timer? Go to the doctor if you think you have one

Now you know the signs, but remember: Just because you can buy over-the-counter treatment for a yeast infection doesn’t mean you always should. The first time you experience symptoms, it’s important to see your doctor (or hit up an urgent care center if you can’t score an appointment) because if it turns out you don’t have a yeast infection, at-home treatments can make inflammation worse or not provide any relief at all, Dr. Goist says.

A doctor will be able to correctly pinpoint the problem (yeast infection or something else) then give you personalized treatment, like an Rx for the oral antifungal fluconazole as well as a topical skin cream to reduce inflammation.

After that, you’ll know exactly what to watch out for, and your doc may give you the all clear to self-treat your next one with an over-the-counter antifungal, like Monistat or generic clotrimazole.

You don’t need products to prevent them

Gynecologists like to call the vagina a “self-cleaning oven.” That’s because it doesn’t need any help with douches, scented gels, perfumes, and other “feminine” products to stay clean. In fact, rather than helping prevent a yeast infection, these can cause an imbalance of the healthy bacteria in your vagina that makes you more susceptible to a yeast infection, explains Dr. Goist.

What to do if it happens after sex

A yeast infection is not technically a sexually transmitted infection (STI), but sex can throw off the bacterial balance in your vagina, upping your risk for a yeast overgrowth. That said, if you get what you think is a yeast infection after sex with a new partner, it’s a good idea to see your doctor, so you can rule out any potential new STIs, as well.

The truth about wet bathing suits

You’ve probably heard hanging out in wet clothes is a recipe for disaster. Doctors often say it’s a good idea to change out of a wet suit or sweaty exercise clothes because yeast thrives in warm, wet environments. And that’s true. But it’s mostly important for women who suffer from recurrent episodes rather than the general population. “Unless you know you’re prone to yeast infections, you won’t necessarily get one by hanging out in a wet suit,” Dr. Goist says. Make changing a priority if you get them frequently, otherwise, you’re probably fine.

Switching birth control pills may make you more susceptible

Anything that alters your hormone levels—like changing to a new hormonal birth control pill (that increases your estrogen levels) or too much stress (high cortisol) is a risk factor. Other things to watch out for: taking antibiotics, which kill healthy bacteria in the vagina, allowing yeast to thrive; or having uncontrolled blood sugar levels if you have type 2 diabetes (high blood sugar can feed yeast). If any of these sound like you and you get yeast infections, come up with a plan with your doc about how to control them.

This article originally appeared on Health.com

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Hillary Clinton Dined With John Kasich Over Healthcare Reform—In 1993

Republican U.S. presidential candidate and Ohio Governor John Kasich formally announces his campaign for the 2016 Republican presidential nomination during a kickoff rally in Columbus
Aaron Bernstein—Reuters Republican presidential candidate and Ohio Governor John Kasich formally announces his campaign for the 2016 Republican presidential nomination.

A decades old meeting between two 2016 rivals takes on new significance.

Just months after her husband took office, First Lady Hillary Clinton attended an unusual backyard dinner in Northern Virginia on her quest to sell the healthcare reform plan known as Hillarycare.

The June 1993 gathering was at the home of then-House Budget Committee ranking member John Kasich, the same man who announced his campaign as a 2016 presidential candidate for a Republican Party still furious about a healthcare reform bill by President Obama that drew heavily on the work of Clinton from the early 1990s.

At the time, Kasich was developing his own national health insurance proposal, which offered a more marketplace-based solution than what emerged in Obamacare. The Kasich plan would have covered all Americans by 2005, using a form of an individual mandate that would have required employees to purchase insurance through their employers. (The mandate was an idea initially supported by conservative groups like the Heritage Foundation.)

In his announcement speech this week, Kasich referred to his work on health issues in the 1990s. “I went on to chair the Health Committee where I learned to work across the aisle because the House was run by Democrats,” Kasich said of his time working in the State Senate. “And that’s where I learned that policy is far more important than politics, ideology, or any of the other nonsense we see.”

In 1993, the bipartisan outreach included the dinner with Clinton and nine fellow Republicans. Afterwards, Kasich declared Clinton had been “a big hit,” with the crowd.

A contemporaneous memo released last year by the Clinton Library provides more insight into the meeting, and Kasich’s role in the healthcare reform effort.

After the dinner, “Congressman Kaslch, has been quite complimentary about you, personally, and the Administration’s consultative and outreach process for health reform,” Clinton aide Chris Jennings wrote to Hillary Clinton in a memo.

Before a follow-up meeting two weeks after the dinner, Jennings pegged Kasich as a strong target for administration outreach. “Kasich, given his reputation as a smart and serious legislator, can be very helpful With mainstream Republicans,” Jennings wrote. “In addition, he seems to have gained the respect of the media so his supportive comments about you and the process can have a positive impact externally on public perception, as well.”

“Even if he ultimately opposes the plan,” Jennings concluded, “his positive feeling toward you and the process may mute his criticism and moderate the Republican opposition effort.”

In 1993, before the Clinton meetings, Kasich released a report on healthcare that amounted to a “rather stereotypical conservative position on health reform,” in Jennings’ words, including means-testing Medicare, increasing co-payments, and using private healthcare savings accounts. But, he added, “it also includes a number of suggestions that are consistent with the direction the Administration has been heading including: Developing incentives for greater use of competition in the Medicare and Medicaid programs, providing flexibility/waiver authority to the states, reducing health care fraud, assuring Insurance portability, establishing purchasing groups, and addressing the medical liability problem.”

A year later, Kasich introduced a plan that would have provided health insurance to all Americans by 2005, requiring them to purchase insurance through their employers on the private market, with government subsidies helping those below or near the federal poverty line. Small businesses and individuals would have been able to join “voluntary alliances” to purchase insurance as a pool. It also ensured that those with pre-existing conditions could get coverage.

Kasich aides said the meeting with Clinton is an example of his willingness to create connections with all sides, including those he disagrees with. “They certainly didn’t agree, but that didn’t keep him from wanting them to engage in converation,” said Kasich spokesman Scott Milburn.

Ultimately, Hillary Clinton’s effort was doomed to failure—though some of its proposals found a home later in the Affordable Care Act.

Many of Kasich’s own ideas for the era were gathered into the Affordable Care Act as well, though Kasich takes issue with their implementation. He has long called for ensuring that all Americans have health care insurance, but, in line with his party’s thinking about the healthcare law, has said he would sign a repeal of the bill.

“He wants to see people cared for, and he wants a competitive free market approach to do it,” Milburn said.

Aides point to Kasich’s turn to expanding managed care healthcare plans in Ohio, which has halved the rate of cost growth, as an example of the types of reforms he is looking to expand nationally.

Kasich frequently defends his decision to expand Medicaid on the campaign trail, tying it to his broader message of compassionate conservatism, arguing that those facing drug addiction, mental illness, and other difficulties should be cared for.

“I’m not for Obamacare.” Kasich told Bloomberg in April. “I have expanded Medicaid, because I wanted to bring Ohio dollars back to Ohio. We’ve been able to apply it to bring significant change, and our ultimate goal is that so all of these people who have been hurt can be in a position to get on their feet and move forward.”

TIME Research

How Having Oily Skin Might Help Prevent Wrinkles

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And why wrinkles tend to be more noticeable around your eyes than on your forehead

Have you ever heard the old wives’ tale that people with oilier skin get fewer wrinkles? There may be some small grain of truth in that after all, according to a new study published in the journal Clinical Anatomy.

For the study, Japanese researchers analyzed the skin on the foreheads and around the eyes in cadavers aged 20 to 90 years old, looking at the wrinkles, the number of sebaceous glands (which are what secrete the skin’s oil), as well as the skin’s elasticity and density. In the end they found that the depth and length of wrinkles correlated to the amount of sebaceous glands in these areas, with areas with more glands tending to have wrinkles that weren’t as deep or long.

This may explain why wrinkles tend to be more noticeable around your eyes (hello, crow’s feet) than on your forehead, since there are more oil-secreting glands in the forehead than around your eyes.

While the authors say it’s possible that oilier skin (thanks to having more glands) prevents dry and deeper wrinkles from forming, the presence of the oil isn’t the only thing that seems to help keep skin smooth. It could also be that the skin on the areas with more glands tended to be thicker and have more elasticity. As the researchers put it: “Such properties will suppress the deformation of the skin.”

Another interesting finding: the density of oil glands was lower in women, than it was for the men, though they didn’t see a big difference in wrinkle depth between the sexes.

Ultimately, what matters more for your skin is the total picture: protecting yourself from the sun’s rays, exercise, eating a healthy diet with lots of foods that are good for your skin, and getting enough sleep.

But hey, if this makes you feel a little bit better about your oily skin, we won’t blame you.

This article originally appeared on Health.com

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What You Should Know About Leaky Gut Syndrome

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What’s a leaky gut, and how do I know if I have one?

“Leaky gut syndrome,” on its own, is a diagnosis that’s not recognized across the board by conventional medicine. The theory is that having a poor diet or ingesting too many antibiotics or painkillers can damage the mucosal barrier, the layer of cells lining your intestine. Normally, this barrier lets nutrients through but blocks larger molecules and germs from getting into your bloodstream. It’s thought that a porous, or “leaky,” intestinal lining can allow food particles or germs to pass into the blood, causing inflammation throughout your body.

Symptoms of a leaky gut are said to include everything from bloating, gas and abdominal pain to recurrent vaginal infections, asthma and mood swings. Some experts even claim that leaky gut can put you at risk of serious conditions such as migraines, rheumatoid arthritis and food allergies.

Is it for real? There is evidence that having high “intestinal permeability” is involved in the development of certain autoimmune diseases, like Crohn’s and type 1 diabetes, in people who are already predisposed to these conditions. But it remains unclear whether intestinal permeability causes issues such as irritable bowel syndrome, food allergies or asthma—or if it’s just a symptom of them. In my experience, having a “leaky gut” is mostly a symptom of a disease, not a disease on its own.

There are tests your doctor can perform to measure how well your intestines are absorbing nutrients and blocking the bad stuff. The most common one involves drinking a mixture of mannitol (a small sugar molecule) and lactulose (a large one) and then testing your urine for each over six hours. But these tests are time-consuming and expensive, and they don’t reveal anything that your doctor can use to recommend treatment. So, honestly, there is no point in getting them.

Some alternative medicine practitioners recommend supplements or home tests (which they conveniently sell on their websites), but ignore these. The best advice for keeping your gut and its lining healthy is to eat plenty of fiber and fermented foods like kefir, or take a probiotic supplement, and stay hydrated.

This article originally appeared on Health.com

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Medicaid Enrollment Surge Causes Concern About State Budgets

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Lucy Nicholson—Reuters Arminda Murillo, 54, reads a leaflet at a health insurance enrollment event in Cudahy, Calif. on March 27, 2014.

Lawmakers warn that the price of expanding could mean less money for other state services

ATLANTA — More than a dozen states that opted to expand Medicaid under the Affordable Care Act have seen enrollments surge way beyond projections, raising concerns that the added costs will strain their budgets when federal aid is scaled back starting in two years.

Some lawmakers warn the price of expanding the health care program for poor and lower-income Americans could mean less money available for other state services, including education.

In Kentucky, for example, enrollments during the 2014 fiscal year were more than double the number projected, with almost 311,000 newly eligible residents signing up. That’s greater than what was initially predicted through 2021. As a result, the state revised its Medicaid cost estimate from $33 million to $74 million for the 2017 fiscal year. By 2021, those costs could climb to a projected $363 million.

“That is a monstrous hole that we have got to figure out how to plug, and we don’t know how to do it,” said Kentucky state Sen. Chris McDaniel, a Republican who leads the Senate budget committee and opposed expansion. “The two biggest things that keep me up at night are state pensions and the cost of expanded Medicaid.”

For patients who have only recently gained access to health care, the program is about far more than dollars and cents. And supporters downplay the budget concerns, pointing to studies that indicate the economic benefits of expanding health care will result in significant savings over time.

Several expansion states have already revised their budget estimates due to the larger than expected enrollments, according to an Associated Press review.

McDaniel said the added Medicaid costs will reduce the pool of money that can be invested in higher education, pension plans or other services.

Supporters of the expansion, including Kentucky Gov. Steve Beshear, predict their states will save money in the long run because Medicaid will allow some state-run services to be eliminated and will stimulate the economy through new revenues and job creation. Beshear, a Democrat, released a study earlier this year touting the creation of 12,000 jobs and nearly $1.2 billion in new revenue to health care providers as a result of expansion.

Thirty states and the District of Columbia have expanded Medicaid, or plan to do so, to include all adults with incomes at or below 138 percent of the federal poverty level, currently $16,243 for an individual.

The federal government agreed to pay all costs for the new enrollees through 2016, but it will begin lowering its share in 2017. States will pay 10 percent of the costs by 2020.

In the expansion states, enrollment for Medicaid and a related program for children have increased an overall 28.2 percent compared with a three-month period before the law’s implementation, according to the federal government. In a recent report, economic experts at the U.S. Department of Health and Human Services said they expect estimated enrollment and per-person cost increases to level off and even decline over the long run.

At least 14 states have seen new enrollments exceed their original projections, causing at least seven to increase their cost estimates for 2017, according to an Associated Press analysis of state budget projections, Medicaid enrollments and cost details in the expansion states. A few states said they could not provide original projections.

California has enrolled nearly 2.3 million people so far — almost three times more than the 800,257 the state had anticipated. Enrollment in neighboring Washington more than doubled. Oregon’s new enrollments have exceeded estimates by 73 percent.

In Michigan, estimated costs have shot up by 50 percent because of soaring enrollment. Ohio’s projected costs more than doubled.

Some states that expanded their Medicaid programs prior to the federal health care law are also seeing enrollment increases based on people signing up because of increased publicity and outreach efforts.

In states where ongoing discussions over Medicaid expansion have yet to be resolved, opponents are quick to cite the surging enrollments and costs. Last month, Republicans in the Florida House repeatedly warned about the costs before soundly defeating an expansion bill.

“Every piece of metrics and data we have seen has showed the Medicaid rolls have exploded,” said state Rep. Blaise Ingoglia. “And it’s putting taxpayers and future prosperity at risk.”

Health care already consumes a large portion of state spending each year, second only to K-12 education. It now represents more than half of all federal funds received by states, according to the National Association of State Budget Officers.

The very nature of Medicaid — that enrollments typically increase in tough economic times — means states must be strong enough financially to continue supporting the expanded program even in future downturns.

An Associated Press review earlier this year found at least 22 states were dealing with budget shortfalls for the 2016 fiscal year.

“In those states that do have budgetary balance, it’s somewhat tenuous,” said credit analyst Gabriel Petek with Standard & Poor’s Ratings Services. Add the cost of rising Medicaid enrollments and “something has to give. Most likely, it means they have to spend less in other areas or they have to increase their tax revenues.”

Oregon originally estimated 222,700 newly eligible Medicaid recipients would sign up by the end of June, but that number ballooned to 386,000.

Paying for the new enrollees isn’t the only Medicaid cost troubling Oregon lawmakers. Starting in 2017, the state loses $1.9 billion in federal aid that has propped up the Medicaid program since 2012 under a special deal with the government.

Between the Medicaid expansion, the lost federal aid and normal growth, Oregon’s Medicaid budget is expected to need $500 million between 2017 and 2019, said Democratic state Sen. Richard Devlin, one of two lawmakers who oversee the budget.

The best solution, he said, is to make sure people are working and don’t need the government health care program.

“I think, really, the only way to keep this manageable is to keep those costs under control, get people off Medicaid,” he said.

For those who were able to sign up for Medicaid when their states expanded eligibility, the program has offered big quality-of-life improvements.

Among them is Earl Charles Williams Sr., a 59-year-old part-time social worker in Chicago. He said he can only imagine what life would be like without the free care he now receives.

His diabetes under control, Williams said his doctor makes sure he comes to the office every few months and keeps him on a healthy regimen.

“There are so many people who really need the care,” he said. “They have nothing. And when they have nothing, you can see the effect on the community.”

Supporters of expanding Medicaid say states will eventually save money by doing away with some of their own services for the uninsured, such as mental and behavioral health programs, and by reducing payments to hospitals and other providers for treatment of the uninsured.

Kentucky saved $9 million in 2014 as enrollees in behavioral and mental health programs were fully covered by Medicaid, according to a report by the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation. Some states, including West Virginia and Arkansas, are reporting costs are lower than expected.

Elsewhere, there are signs that some of the hoped-for savings might not be realized quickly.

In New Mexico, where enrollment under the Medicaid expansion surpassed projections by 44 percent, legislative analysts warned last month that the state will not save as much money as originally projected because cost-containing measures have proven difficult to implement.

In addition, legislative staff said New Mexico lawmakers will have to consider taking money from other state agencies to fill the gap.

“When you’re looking at a state budget and there are only so many dollars to go around, obviously it’s a concern,” said state Sen. Howie Morales, a Democrat who sits on the powerful Legislative Finance Committee. “The most vulnerable of our citizens — the children, our senior citizens, our veterans, individuals with disabilities — I get concerned that those could be areas that get hit.”

Associated Press writers Adam Beam in Frankfort, Kentucky; Susan Montoya Bryan in Albuquerque, New Mexico; Jonathan J. Cooper in Salem, Oregon; Carla K. Johnson in Chicago; Kelli Kennedy in Miami; Judy Lin in Sacramento, California; and Gosia Wozniacka in Portland, Oregon, contributed to this report.

TIME Research

5 Weird Ways Ovulation Can Affect Your Body

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Your senses might seem heightened

Once a month, women of reproductive age go through ovulation—the process in which an egg is released from an ovary into the fallopian tubes, which can then be fertilized by sperm. At the same time, our hormones begin to fluctuate and our brain chemistry shifts, which may be an attempt to help the baby-making along. These changes are thought to increase chances of conception, with research in recent years revealing that ovulation may affect your brain, body, and behavior in surprising ways.

“Hormones affect the entire body, not just the reproductive organs, so it makes sense that our thinking, our behavior, even our appearance can change throughout our cycles,” says Carol Gnatuk, MD, assistant professor of obstetrics and gynecology at Penn State Milton S. Hershey Medical Center. Here are some of the more surprising, even mysterious, symptoms you may notice during your most fertile time of the month.

Your face may get (ever so slightly) redder

First, a new study published in the journal PLoS One found that women’s faces become slightly more flushed in the days leading up to and during ovulation. This makes sense, Dr. Gnatuk says, since hormones affect blood flow throughout the body. “Higher estrogen levels during ovulation can cause blood vessels to dilate, and when vessels dilate close to the skin you get more of a glow,” she says.

The study authors had assumed this affect might be noticeable to men, and might begin to solve the mystery of how and why men seem to find women who are ovulating more sexually attractive. But the slight increase in redness was only detectable via very sensitive cameras—not to the naked eye, which means the jury’s still out.

You might feel more frisky (and express it in interesting ways)

Evolutionarily, it makes sense that a woman’s libido goes up during the time of the month she’s most fertile. But ovulating women don’t just consciously think more about sex; it’s on their mind in sneakier ways as well. According to a 2010 study in the Journal of Consumer Research, during ovulation women may be more likely to unconsciously buy and wear sexier clothing.

Research has also suggested that women dream more about sex in the first half of the menstrual cycle, when the body is gearing up for ovulation, compared to the second half, when your body prepares for your period. One small study found women may even have more erotic interpretations of abstract artwork (think Georgia O’Keeffe flower paintings) when they’re ovulating versus later in their menstrual cycles.

“Libido isn’t totally driven by hormones—if it were, sex would only be about when and not where or with who,” Dr. Gnatuk says. “But certainly, estrogen and testosterone, both of which are higher during ovulation, can increase a woman’s desire.”

You may be more attracted to a certain type of guy

Not only might you feel more “in the mood” during ovulation, but you may also be more interested in some guys over others. Studies have shown that women tend to prefer men with sterotypically masculine traits and pay more attention to traditionally attractive guys during fertile times of the month, especially if their current partners lack manly facial features, like a square jaw.

“When we’re in reproductive mode, we look for traits that we associate with good health,” Dr. Gnatuk explains—and that includes healthy testosterone levels, she says, which suggest that a man is well able to produce and protect offspring.

Another 2011 study from the journal Psychological Science suggests women are better at judging men’s sexual orientation when they are ovulating, perhaps since, from an evolutionary perspective, there’s no sense in going after a guy who isn’t interested.

Your senses might seem heightened

Ovulating women seem to be better able to detect musky odors and male pheromones than those taking oral contraceptives (which prevent ovulation), according to a small 2013 study in the journal Hormones and Behavior; another study that same year found that women may have a heightened sense of smell in general during ovulation than during other times of the month.

You may even be better at detecting potential threats to yourself and your future offspring: A preliminary 2012 study by Kyoto University researchers found that women in the luteal phase of their cycles (which begins with ovulation) were better at finding snakes hidden in photographs of flowers.

You could avoid male relatives

And finally, here’s perhaps one of the most bizarre side effects of ovulation found in the research: According to a 2010 UCLA study, women avoid talking to their fathers on the phone during their most fertile times of the month. (Those who were ovulating or about to ovulate were half as likely to chat with Dad, on average.)

The researchers speculated that historically, it was in a woman’s (and her offspring’s) best interest to avoid male relatives—and potentially incestuous couplings—while they were fertile. Dr. Gnatuk has an alternate interpretation: “You might also argue that you don’t want to talk to Dad right now because he always told you you couldn’t go out with guys, and now’s the time you want to do that.”

This article originally appeared on Health.com

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Everything You Need to Know About Your Gallbladder

Plus how to deal with gallstones

Your gallbladder is like a little storage sac: It sits under your liver, collecting bile until the liquid is needed to help break down fats. After you eat fatty foods, your gallbladder contracts to pump bile into your small intestine for digestion. William Silverman, MD, a professor of medicine in the Division of Gastroenterology and Hepatology at the University of Iowa Hospitals and Clinics and the Iowa governor of the American College of Gastroenterology, says that when people develop a problem in this pear-shaped organ, it’s typically one of two things: “Gallstones, which are incredibly common, or gallbladder cancer, which is exceedingly rare.” Read on to learn more about both.

What exactly are gallstones?

In most cases, gallstones are small pieces of crystallized cholesterol. (The pebble-like lumps can form when there’s an imbalance of substances in the bile.) More than 25 million Americans have them—but most never even know it. Symptoms—and possibly infection—strike when the stones get stuck in the gallbladder’s narrow outlet, or in the ducts that drain the organ.

Women are more likely to get gallstones

This is especially true as we age. (Gallstones occur in almost a quarter of women by age 60.) It’s thought that the female hormone estrogen stimulates the liver to divert cholesterol into bile.

Pregnancy ups your risk. “During pregnancy you secrete the hormone progesterone in an increased amount and that decreases the gallbladder contraction,” explains Dr. Silverman. Bile lingering in the organ may become stagnant and stones may precipitate out.

Who else is at risk?

Certain populations are predisposed to gallstones, says Dr. Silverman, including the Pima Indians in Arizona. But most cases aren’t related to genetics, he says.

Waist size, however, does play a role: A large 2013 study published in Hepatology found that the higher a woman’s BMI, the more likely she was to develop gallstones.

Diabetes also raises a person’s risk, as well as bariatric surgery and extreme weight loss. (Gallstones are one of the reasons you should seek medical supervision when you hope to lose a large amount of weight.)

But the truth is, the majority of people who get gallstones don’t have any of the major known risk factors, says Dr. Silverman. “That would suggest that there are many things that we still really don’t understand.”

How are gallstones treated?

Sometimes doctors discover gallstones by accident while looking for something else. In that case it’s generally best to leave them alone. But if you’re experiencing symptoms, your doc will likely suggest cholescystectomy—an operation to remove the gallbladder (which may be done laparoscopically). Fortunately, the organ isn’t essential; once it’s gone, bile will flow directly from your liver to your small intestine.

Are there non-surgical options?

Oral medications are sometimes prescribed to patients who can’t undergo surgery, although it may take months or years for them to work, if they work at all.

In the 1980s, doctors began experimenting with a procedure called extracorporeal shock wave lithotripsy, which successfully pulverized gallstones using sound waves. But the treatment has since fallen out of use. “The stones would simply recur for whatever reasons caused them in the first place,” explains Dr. Silverman.

In the slides ahead you’ll find the most common signs of a gallbladder problem.

Symptom: Pain in the upper right abdomen

This is where your gallbladder is located, just beneath your liver. Sudden, extreme pain could mean that stones are causing a blockage: Your gallbladder may be contracting but unable to drain, “so pressure builds up and it hurts,” explains Dr. Silverman. But there are many other reasons you might experience pain in this area, he stresses, including muscle spasms. Call your doctor for emergency advice.

Sudden, intensifying pain in your intestines—located in the center of your abdomen—could also be a sign of gallstones.

Symptoms: Fever and chills with abdominal pain

A blockage by gallstones can cause a buildup of bile in the gallbladder, which may lead to an infection called cholecystitis. Pain, chills, and a fever of 100.4 degrees or higher are classic symptoms, and may come on after a big meal. There are a variety of ways to detect the problem, including blood tests and a scan that tracks the flow of bile. If you’re diagnosed, your MD will likely want to check you into the hospital. The treatment might involve fasting, antibiotics, and pain meds until the inflammation subsides.

Symptoms: A change in the color of your urine and stools

Bile salts are what make stools brown. If you noticed that your number-twos are pale or clay-colored, that might indicate that a gallstone is blocking the bile duct.

Your urine can also provide a clue. When there is excess bile building up in the body, it can turn your pee a darker, orange color.

Yellowing of your skin and eyes may occur as well. Read on for more about jaundice.

Symptom: Yellowing of the skin and eyes

Jaundice can by a sign of gallstones, but when it’s accompanied by abdominal pain and weight loss, it may be a symptom of gallbladder cancer. If a tumor is blocking the flow of bile, the yellow-brown fluid may build up in the body and give the skin and the whites of the eyes a yellow tint. Keep in mind, though, that jaundice is caused more often by hepatitis than cancer. In any case, it’s a good idea to see your doctor right away.

A sign you may need your gallbladder removed

Gallbladder polyps are growths on the inside of the gallbladder wall show up on ultrasounds, often when doctors are investigating unrelated problems. Most of the time, they’re nothing to worry about. But people with big polyps have a higher risk of developing gallbladder cancer, Dr. Silverman says: “I would emphasize that these are very large polyps, not tiny ones.” As a preventative measure, your doctor may recommend gallbladder removal.

What about gallbladder cancer?

People who have a history of gallstones or large polyps are more likely to develop gallbladder cancer—but even among this group, the risk is very small. The American Cancer Society estimates there are fewer than 11,000 cases diagnosed per year. Still, if you’ve dealt with gallbladder problems in the past and begin experiencing abdominal pain, bloating, itchiness, loss of fever, nausea, or unexplained weight loss, then make an appointment with your doctor.

This article originally appeared on Health.com

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12 Germs That Can Cause Food Poisoning

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These stomach bugs can lead to various forms of misery

In most cases of food poisoning, a microbe in something you ate (or a pathogen that goes from your hand to your mouth) irritates your stomach and intestines—and the consequences aren’t pretty, with symptoms that range from a mildly upset tummy to vomiting and bloody diarrhea. Even though the United States has one of the safest food supplies in the world, one in six people suffer foodborne illness every year, according to government estimates.

Read on to learn about some of the most common bugs that might be lurking in your lunch.

How do you treat food poisoning?

As long as you’re otherwise healthy, most cases of gastroenteritis (inflammation in the intestines caused by a virus, bacteria, or parasites) don’t require treatment. Your body will (eventually) expel the bugs that are making you sick. There’s not much you can do aside from rest and sip plenty of fluids. (Electrolyte-rich liquids like broth and coconut water are best.) You may be tempted to pop an OTC anti-diarrhea product, but ask your MD first; it may interfere with the natural healing process. Once you’re keeping fluids down, slowly reintroduce solids, starting with bland, low-fiber food like the BRAT diet (bananas, rice, applesauce, and toast).

In more serious cases, you may want to get checked out by a doctor. Watch for any of these signs that warrant medical attention: Diarrhea with a fever above 101 degrees F; dizziness, lightheadedness, or intense thirst; an inability to keep anything down for 24 hours; diarrhea that lasts for five days or more.

Norovirus

Norovirus is the pathogen responsible for outbreaks of vomiting and diarrhea on cruise ships, but a 2014 Centers for Disease Control and Prevention (CDC) report found that you’re far more likely to pick up the bug in a restaurant or cafeteria. Norovirus is the most common cause of gastroenteritis in the U.S., infecting more than 19 million people a year.

What you need to know: It’s highly contagious: The number of virus particles that fit on the head of a pin would be enough to make more than 1,000 people sick. Symptoms should resolve within 60 hours, but you may continue to spread the pathogen for two weeks or more.

How to avoid it: Wash fruits and veggies well, and cook shellfish thoroughly. (Norovirus can survive temps as high as 140 degrees.) And be sure to wash your hands (like, really wash them). You can also get the pathogen from contact with an infected person, or by touching a contaminated surface.

Salmonella

Batter-covered spoon lickers, beware: the strain of Salmonella that causes most illnesses today infects the ovaries of hens, which then lay contaminated eggs. The bacteria are also found in as many as one in eight chickens raised for meat, according to the USDA. Each year,Salmonella causes four to seven days of misery (including cramps, diarrhea, and fever) for approximately 1.2 million Americans.

What you need to know:Salmonella can also contaminate other types of meat and seafood, cheese, unpasteurized milk and juice, and raw produce.

How to avoid it: Say no to sunny-side-up and soft-boiled eggs. Eggs with firm yolks and whites are safest to eat. Heat your poultry to 165 degrees, and ground beef to 160 degrees.

Botulism

Spores of C. botulinum produce a neurotoxin that causes botulism—a rare but severe type of food poisoning that can lead to respiratory failure and death. Most of the 10 to 30 outbreaks of botulism reported each year can be traced to home-canned foods, according to the FDA.

What you need to know: Classic symptoms include double vision, slurred speech, difficulty swallowing, and muscle weakness. If you think you might have botulism, seek medical help immediately. Prompt treatment with an antitoxin can block the effects of the poison.

How to avoid it: The Mayo Clinic recommends boiling home-canned foods for 10 minutes before you eat them. Other tips: Eat baked potatoes wrapped in foil while they’re still hot (not at room temperature), and store oils infused with garlic or herbs in the fridge.

E. coli

E. coli naturally live inside humans and animals, and for the most part, the bacteria are harmless. But a few strains—including the notorious O157:H7— can wreak havoc on the lining of your small intestine when ingested. Expect bloody diarrhea, plus vomiting and severe stomach cramps.

What you need to know: Runoff from cattle farms can spread E. colito produce grown in nearby fields. Spinach and lettuce are especially susceptible to contamination.

How to avoid it: A 2015 report that examined 1,000 E. coli cases found that 80% were linked to vegetables or beef. Ground beef is a common source of infection because it contains meat from many cows—so order your burgers medium or well-done.

Campylobacter

Responsible for an estimated 1.3 million cases of campylobacteriosis a year, this pathogen can come from unpasteurized dairy products (if a cow had a Campylobacter infection in her udder, for example). But most cases are linked to raw or undercooked meat or poultry. The good news: Symptoms usually resolve on their own. The bad news: The diarrhea, cramping, and fever last about a week.

What you need to know: Even one drop of juice from contaminated raw chicken meat can make you sick.

How to avoid it: While you’re cooking, use a separate cutting board for raw meat to avoid cross-contaminating veggies and other foods. And don’t skimp on the cleanup: Scrub the cutting board, countertops, and utensils with soap and hot water.

Listeria

Pregnant women worry about this foodborne pathogen. It can cause listeriosis, which may lead to miscarriage or a serious illness for the newborn. But anyone with a weakened immune system is at higher risk for the infection, with symptoms ranging from a stiff neck to convulsions and loss of balance. An estimated 1,600 cases occur in this country annually.

What you need to know: Although pasteurization and high temperatures kill Listeria, cold cuts and deli meats are a common source of the bacteria because contamination may occur at the deli counter, or in the factory (after cooking but before packaging).

How to avoid it: According to the CDC, people at higher risk should skip ready-to-eat meats, unless they’re heated to steaming hot before serving. Other foods on the avoid list: Refrigerated pate or meat spreads from a deli counter, soft cheese made with unpasteurized milk, and refrigerated smoked seafood (like lox).

Staph

Many people have Staphylococcus aureus all over their skin, and the bacteria typically doesn’t cause any issues. Until, that is, it gets in our food. As the bugs multiply, they produce toxins that quickly trigger the classic symptoms of food poisoning—sometimes as soon as an hour later.

What you need to know: Handmade foods that don’t require further cooking are the likeliest suspects: Think prepared salads (from macaroni to tuna), sandwiches, and cream-filled bakery desserts.

How to avoid it: Practice good hand hygiene. Stay away from the kitchen when you have a nose or eye infection, or wounds or skin infections on your hands or wrists.

Clostridium perfringens

C. perfringens may live in your intestine without doing any harm. But when you ingest large numbers of the toxin-producing bacteria, cramps and diarrhea strike with a vengeance for up to 24 hours.

What you need to know: C. perfringens is one of the most frequent causes of food poisoning in the U.S. Outbreaks often occur in cafeterias and at catered events, because the bacteria’s spores can germinate in food that’s cooled or warmed at temperatures between 54 and 140 degrees F for long periods of time.

How to avoid it: To destroy C. perfringens on food that’s been sitting out or stored as leftovers, reheat it to 165 degrees F.

Shigella

Disgusting but true: This highly contagious group of bacteria is spread through stool. You can pick up the bug in food contaminated by an infected person, or on produce grown in a field that contains (yikes) human sewage. The result: GI distress and tenesmus, the painful sensation of needing to go number-two even when your bowels are empty.

What you need to know: Shigella is a common cause of traveler’s diarrhea (a.k.a. Montezuma’s revenge and Delhi belly). Although it usually goes away on its own in five to seven days, docs often prescribe antibiotics for mild cases to speed the process. Now, drug-resistant shigellosis is on the rise in the U.S.

How to avoid it: When traveling in a developing country, order carefully. Steaming hot foods are generally safe, for example, and drinks that come in sealed containers. You can also download the CDC’s “Can I Eat This?” app, which has info tailored to different countries.

Bacillus cereus

This nasty little bug causes not one, but two kinds of food poisoning: A type associated with diarrhea and another with vomiting. Fortunately, both only last for about 24 hours. In the meantime, try to stay hydrated.

What you need to know: Rice that’s been sitting at room temperature is generally implicated in vomiting-type outbreaks. But the bacteria are found on a wide variety of foods and multiple rapidly at room temperature.

How to avoid it: Be careful not to let leftovers sit out for too long. Store them in the fridge in wide, shallow containers ASAP. Prepping ahead of a meal? If it’s more than two hours ’til chow time, keep cold items at 40 degrees or below, and keep hot foods at a minimum temp of 140.

Toxoplasma gondii

You might recognize this microbe as the reason pregnant women are told to stay away from cats’ litter boxes. But the single-celled parasite is also spread in undercooked, contaminated meat—especially pork, lamb, and venison. Most people who’ve picked up the bug (the CDC estimates 60 million people in the U.S.) don’t even know they have it. But in anyone with compromised immunity, it can cause the disease toxoplasmosis.

What you need to know: Symptoms of toxoplasmosis vary widely: Some people might think they have the flu for a month or more, while severe cases can cause brain damage.

How to avoid it: There’s not much you can do aside from following general food safety protocol.

Vibrio parahaemolyticus

Found in brackish waters, estuaries, and coastal bays, this bacterium thrives during the warm, summer months and is known to contaminate shellfish. Infection with V. parahaemolyticus is no fun. Watery diarrhea, cramps, vomiting, fever—you get the picture. These symptoms typically last up to three days.

What you need to know: Raw oysters are the usual culprit.

How to avoid it: Steer clear of the raw bar if you’re worried about getting sick. Cooking shellfish at home? Boil osyters, clams, and mussels for five minutes after the shells open, or steam until the shells open. (Toss any that don’t.) Boil shucked oysters for a minimum of three minutes, or fry in oil at 375 degrees for at least three minutes.

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