The ACA and OTC Medications – What Physicians Need to Know About Changes in Coverage

January 1 has come and gone, but many of us are unaware of some of the changes with the Affordable Care Act, particularly related to coverage of medications and supplements that became effective in 2014. For our patients who are enrolled in ACA-compliant plans, certain over-the-counter (OTC) medications are now covered at no cost when written as a prescription. Translation: Write prescriptions for these medications when medically necessary.

As an example, aspirin is now a covered medication under the ACA for women ages 55–79 when the benefit of reducing heart attacks outweighs the risk of gastrointestinal bleeding. The cost of OTC emergency contraception is also covered if a prescription is written for it. Vitamin D supplements are covered for women ages 65 and older to prevent fractures. And folic acid supplements are covered for women capable of becoming pregnant.

This change in insurance coverage comes at a time when research is looking closely at the benefits of supplements. Certainly all of us are confused at times when related research appears in the media and the benefits of vitamins and supplements are questioned. That’s why we as physicians need to make recommendations to our patients based on their individual needs. This ensures that reproductive-age women don’t forgo important and proven supplements—for instance, folic acid to reduce birth defects like spina bifida—based on a single study.

As physicians, we are in a position to not only recommend, but to reinforce the use of these medications and vitamin supplements for preventive health. It’s up to us health care providers to recommend and prescribe them.

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To Supplement or Not to Supplement

Do you take calcium and vitamin D supplements? If you’re a woman over 60, chances are you do. More than half of women in this age range take these dietary supplements, and for good reason. Fully 80% of the 10 million people in the US with osteoporosis—a debilitating disease marked by porous, fragile bones—are women. Another 37%–50% of women over 50 have osteopenia (low bone mass). Both conditions put sufferers at risk for bone fractures, which can take longer to heal as you age and can cause major mobility problems, and sometimes death.

So when the US Preventive Services Task Force (USPSTF) recently recommended that postmenopausal women should stop taking calcium and vitamin D supplements, it caused some confusion. The USPSTF concluded that the small risk of kidney stones associated with taking calcium and vitamin D outweighs the protection against bone fractures that most postmenopausal women receive from the supplements.

ACOG and the Institute of Medicine recommend that women over 50 get 1200 mg/day of calcium and 600 IU/day of vitamin D (800 IU/day in women 71 and older). The National Osteoporosis Foundation has similar recommendations.

While the debate continues, there are a few facts we can all agree on:

  • Calcium is a nutrient that’s vital to bone health and vitamin D helps the body to use it efficiently
  • It’s important that women get enough of these bone-protecting nutrients
  • Supplements can help you reach optimal levels, but they don’t replace the need for eating a variety of foods with calcium and vitamin D

The average American only gets 500 to 750 mgs of calcium each day, far short of the recommended daily intake. You can increase your daily levels by eating calcium-rich foods such as lowfat dairy (yogurt, cheese, milk), dark leafy greens (kale, collards, spinach), and canned fish with soft bones (salmon and sardines). You can get more vitamin D by eating fortified foods such as milk or cereal, or aiming for 15 minutes of sun exposure on your hands and face or arms a few days each week. Weight-bearing exercise, such as walking, tennis, dancing, yoga, or tai chi, can help strengthen bones, too.

For some women, certain types of hormone therapy and other medications containing bisphosphonates, estrogen, and calcitonin can also help prevent fractures. Talk to your doctor. He or she can determine whether you’re getting enough calcium and vitamin D, suggest a supplement to make up for what you’re missing in diet alone, or help choose a medication that may work for you.

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A Vitamin for Healthy Moms and Babies

Pop Quiz: What vitamin is associated with a 50–70% reduction in birth defects? Answer: Folic Acid

I recently wrote about the importance of eating your vitamins through food, but getting enough folic acid from natural sources can be tough. Folic acid is an essential B vitamin necessary for proper cell growth. It’s vital to the development of a baby’s brain, spinal cord, and central nervous system and integral in preventing birth defects such as spina bifida, anencephaly, and cleft lip and palate. Here’s the catch: In order for folic acid to provide the best protection against birth defects, levels of the vitamin need to be high in a woman’s body before she becomes pregnant and through the first three months of pregnancy.

Because nearly half of the pregnancies in the US are unintended, it’s important that reproductive-age women build up their folic acid stores, whether planning a pregnancy or not. ACOG recommends that all childbearing-age women take 400 micrograms of folic acid each day. Women who have had a child with a neural tube defect or certain other birth defects, are pregnant with twins, have particular medical conditions (such as sickle cell disease), or take some forms of medication (such as antiseizure medication) may need more.

Our bodies can’t process folate—the naturally occurring form of folic acid found in leafy green vegetables, citrus fruits, and beans—as easily as the man-made form. Folic acid-enriched breakfast cereals, breads, flours, pastas, rice, and other grains can help, but even women who eat diets high in these sources may not get enough. To make sure you get the recommended amount, take a daily supplement or multivitamin containing 0.4 milligrams or 400 micrograms of folic acid.

Summertime and the Eatin’ Is Easy

Do you struggle to eat right? Do you count the piece of lettuce and slice of tomato on your burger as two servings of vegetables? Does your usual fish serving come in a deep-fried square slathered in tartar sauce? If you answered “yes” to any of these questions, you may have considered taking a multivitamin to fill in the gaps of a less-than-perfect menu, and you have a lot of company. An estimated 110 million Americans buy vitamin supplements each year.

For those of you hoping for a salad bar in pill form, I’ve got bad news: A growing body of research says that vitamin and nutritional supplements leave a lot to be desired. While these supplements can be helpful in staving off common deficiencies, such as low iron in premenopausal women or inadequate calcium in postmenopausal women, often touted claims of cancer prevention, heart protection, and overall improved health have not been proven.

If you have a health problem related to a deficiency, it’s best to consult with your doctor on the best way to right what’s wrong. But for many women, a colorful and varied diet containing an abundance of whole foods, such as fruits, vegetables, healthy fats, and whole grains, still trumps anything you can buy in a bottle. Whole foods contain not just one or a few isolated vitamins and nutrients, but a number of components—think fiber, minerals, antioxidants, water content, etc—that work together to make the whole greater than the sum of its parts.

This summer, I challenge you to think about your food choices more holistically. Look for natural sources for the nutrients you need. Aim to get your calcium from low-fat dairy and leafy greens, and your fish oils from actual (not fried) fish. For those of you in climates where gardens will soon overflow with fresh produce, work in more servings of what’s in season near you. No matter where you are, shoot for 7–9 servings of fruits and vegetables each day (it IS possible), make at least half of your grain servings of the whole grain variety, and get plenty of protein from low-fat sources like beans, nuts, and lean meats. By the end of the season, you may find that getting your vitamins the way nature intended isn’t as hard as you thought.