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I'm john strum, and this is real talk, mississippi. It's May 5th and we have a lot to talk about. Family planning means learning about and choosing when, whether and how to have children, and when you're living with Ms. That means getting a few more questions answered and taking a few more variables into consideration. My guest today is Dr. Riley Bovet, a practicing neurologist and clinician scientist at the UCSF Weil Institute for Neurosciences. Dr. Bovet is one of the world's leading experts on Ms. And women's health issues, from family planning to pregnancy to menopause, and I am always thrilled to have her join me on the podcast. But before we get to my conversation with Dr. Bovet, there are a few other things that you should know about. I wonder how many of you have heard the expression health care by zip code. It refers to the sad reality that access to health care across the United States isn't equal to. It refers to the challenges that people living in typically poor neighborhoods face whenever they attempt to access any part of the healthcare ecosystem, from finding qualified medical specialists, to locating a pharmacy in their neighborhood to handle their prescription medications, to even having access to some of those medications. Results of a study presented just a couple of weeks ago at the American Academy of Neurology's annual meeting show that in some states Medicaid coverage fails to include high efficacy disease modifying therapies. And in many states high efficacy disease modifying therapies are only available if the patient and their neurologist are willing to run the authorization gauntlet. Today there are more than 20 disease modifying therapies that have been approved for treating Ms. In the United States. But all of these DMTs do not offer the same level of effectiveness. The evidence is pretty clear. So called high efficacy disease modifying therapies are better at reducing relapse rates and delaying disability progression. And when we talk about high efficacy DMTs, we're talking about Ocrevus, Qysimta, Brienvi and Tysabri. In this study, the research team analyzed 2024 Medicaid state drug utilization data for 27 different FDA approved Ms. Therapies in all 50, along with 462 Medicaid preferred drug lists and data that showed prior authorization for drugs on these Medicaid preferred drug lists. When you're thinking about those 462 Medicaid preferred drug lists, it's important to keep in mind that Medicaid is a federal program that's administered by each state and in many states multiple Medicaid plans are offered by private insurers operating under state contracts, while there are some states that run fee for service plans directly. So as you might expect, Medicaid coverage for an estimated 80 to 90 million low income Americans is widely varied from one state to another. In conducting their analysis, the researchers found that high efficacy disease modifying therapies are not covered in about 42% of the Medicaid plans they reviewed, with nine states offering no Medicaid coverage of high efficacy DMTs at all. Less than 25% of the Medicaid plans had at least two high efficacy therapies that did not require prior authorization, making access to these medications much easier but still limiting options, which are particularly important because we all know that not every disease modifying therapy is going to work for every individual. Evidence shows that early initiation of high efficacy treatments improves long term outcomes. Unfortunately, evidence also shows that these treatments are not readily available for all Medicaid beneficiaries, creating a two tier framework for treating Ms. A healthcare framework based solely on socioeconomics we don't allow this sort of discrimination to exist in other areas of society, and it certainly shouldn't exist when it comes to taking care of individuals with chronic health conditions like multiple sclerosis. If you'd like to review the details of this study, you'll find that link in today's show. Notes. While we're talking about access to quality healthcare, it's also worth noting that this year enrollment in Affordable Care act individual health care plans has declined somewhere between 17 and 26%, translating to about 5 million people who haven't renewed their health insurance plans that were purchased through the ACA online marketplace. Last year, when Congress allowed the enhanced premium tax credits for these health insurance policies to expire at the end of 2025, the premiums for these policies skyrocketed and 2026 has already seen a large number of insured patients downgrade their insurance coverage, going from a gold plan to a silver plan or a silver plan to a bronze plan, with some bronze plans carrying lower premiums but annual deductibles that can reach more than $10,000. This year, enrollment in silver plans has declined by 17% and enrollment in gold plans has declined by 6.3%, while enrollment in bronze plans has expanded by almost 11%. Now, all this activity has two consequences. First, death rates are expected to increase between 2.9 and 6.5%, and second, insurance premiums for everyone who is still covered by an ACA Marketplace health insurance plan have to go up again next year, and I'LL explain why insurance premiums are based upon who is in the pool of insured people. That pool is made up of a mix of people ranging from those who are extremely healthy to those who are extremely unhealthy. With everything and everyone in between those extremes. The insurance companies need to have enough relatively healthy people paying their premiums but not needing health care to offset those people whose health care utilization is extremely high. That's the formula for success in the insurance industry. When premiums skyrocketed at the beginning of this year, the people who canceled their health care coverage were mostly people who were extremely healthy. Many of them simply decided they didn't want to pay the large increase in cost for a service they didn't really use. So the healthy people were the ones who left the pool. And who did that leave in the pool? People with significant chronic health conditions. People who needed health insurance because their health care utilization was so high. But now the insurance companies didn't have the premiums from the healthy people to offset the costs of the people with serious medical conditions. Insurance companies aren't built to lose money. So how do they offset rising costs? By raising your 2027 health insurance premiums to cover those increased costs. And that's exactly what health economists expect to happen. So what can you do about this? Well, at the end of the day, this is a matter of public policy. Congress decides whether and by how much to support the Affordable Care act, just like it did at the end of 2025 when Congress allowed those enhanced premium tax credits to expire. That decision set all of this chaos in the private health insurance marketplace into motion. So, circling back to my question, what can you do about this? You can vote on behalf of your own self interest. You can choose to support congressional candidates that support you. And as we approach the midterm elections, we'll be talking about ways you can identify those candidates. Like every Ms. Activist, I want to see important medical research funded and people living with Ms. Able to access affordable care and affordable medications. And by the way, I believe those are nonpartisan goals. So as we get closer to the midterm elections, be ready. Because that election will be your opportunity to take action and vote and like your future health care depended on it. Cognitive behavioral therapy, or cbt, is a type of talk therapy that focuses on identifying and modifying negative thoughts and behaviors. And an analysis of 22 published studies indicates that cognitive behavioral therapy, whether it's delivered online, by phone, or in person, can improve Ms. Related depression within about a couple of months. This Meta analysis of 22 different studies conducted in the US the UK, Iran, Italy and Germany involved more than 1500 participants with Ms. Of the 22 studies, 20 of them were randomized controlled studies in which participants were randomly placed into either a group that received CBT or a group that didn't. In some of these studies, CBT was delivered in one to one sessions. In other studies, CBT was delivered in group sessions. The sessions themselves lasted anywhere from 30 minutes to 2 hours over anywhere from 6 to 16 weeks and regardless of the delivery method, after about 8 to 12 weeks of treatment. CBT helped ease depression in adults with ms, and those benefits seem to last about six months, suggesting that follow up CBT sessions could be helpful in extending those benefits. Evidence shows that one in every two people living with Ms. Will experience clinical depression, and while there isn't a cure for ms, there are effective treatments for depression. CBT gives you a treatment option that's as close as your nearest screen. If you'd like to review the details of this meta analysis, you'll find that link in today's show. Notes. There's plenty of evidence that shows exercise is beneficial for people living with Ms. At every level of ability, but there's been far less understood about which biological mechanisms are actually impacted by exercise until now. A research team in Italy has published study results that may explain actual changes that may occur in the immune system when someone exercises. In this study, some mice with the mouse version of Ms. Exercised regularly on a running wheel while other mice didn't, and as would be expected, the mice that exercised had less severe disease. Exercise also changed the T cells in the mice that exercised. Now, T cells are immune cells that help to regulate inflammation, and the mice that exercised had lower levels of pro inflammatory T cells and higher levels of regulatory T cells which helped suppress inflammation. Now, this is a time when I would typically issue my standard disclaimer that there are huge differences between a mouse brain and a human brain, and while these are encouraging results, we still need to see what happens when humans are put through the same type of study. However, this research team also ran a small pilot study that focused on an eight week exercise program for 18 people with progressive Ms. The results of this pilot study showed that the exercise program led to improvements in clinical and and patient reported outcomes. The study participants reported reduced anxiety and improvements in energy and their physical quality of life, while the researchers found changes in their T cell metabolism, supporting the idea that the biological mechanisms that were observed in the mice were also taking place in people. Based on the positive outcome of this pilot study1 larger studies are needed to explore how understanding and leveraging these mechanisms might lead to new treatment pathways for people living with Ms. I want to remind you that this episode of Real Talk Ms. Is sponsored by Able Now, a tax advantaged savings program for people with disabilities. If you're living with multiple sclerosis, this is important news. Expanded federal rules mean more adults with disabilities, including many people with ms, can open an ablenow account. Ablenow lets individuals save and invest money without affecting their eligibility for certain public benefits, such as SSI or Medicaid. For many of you, it can be an essential financial tool. To learn more and understand if you're eligible to open an account, visit ablenow.com and you'll find that link in today's show. Notes While we're delivering positive research outcomes, there are several recent positive research outcomes that should be of particular interest to people with Ms. Who are contemplating pregnancy. We'll get into all of them in a moment when we meet my guest, Dr. Riley Bovet. Family planning means learning about and choosing when, whether and how to have children. Living with Ms. May be one more factor to consider when making those plans. It's always my pleasure to welcome Dr. Riley Bovet to the podcast. Dr. Bovet is a practicing neurologist and clinician scientist at the UCSF Weill Institute for Neurosciences. She has a special interest in women's health issues in ms, from family planning and pregnancy to menopause, and publishes, collaborates and lectures on these very important issues. Welcome back to the podcast, Dr. Bovet.