Sunday, May 21, 2017

Ky. is a national leader in hepatitis C, but many counties at risk shun syringe exchanges that could prevent disease outbreaks

"Growing intravenous drug use by people sharing syringes to inject heroin and other substances" has helped make Kentucky a national hotbed for cases of hepatitis C, "which ultimately could mean a staggering cost to taxpayers to treat people with the disease," Bill Estep reports for the Lexington Herald-Leader.

"Giving addicts clean needles can help stem the spread of the disease, but many Kentucky counties considered at greatest risk for an outbreak have not approved such programs," Estep notes. His story has a map of syringe exchanges and the Kentucky counties that the federal Centers for Disease Control and Prevention considers most at risk for an outbreak of HIV or hepatitis C due to IV drug use. Of the 220 counties identified, Kentucky has 54, almost half its total number of counties.
Lexington Herald-Leader map
"The programs have only been legal in Kentucky since 2015, when the legislature authorized them in the face of mounting IV drug use," Estep notes. Now there are 33, nine of which are not in operation yet. They are run by local health departments with approval of the county fiscal court and the city where the exchange is located.

"Despite the documented problems, more than 30 of the counties the CDC identified as being at high risk for a disease outbreak have not set up needle-exchange programs," Estep reports. "Some local officials said they’ve faced concerns from residents of their culturally and politically conservative counties that giving needles to drug users condones or perpetuates drug abuse."

Russell County Judge-Executive Gary Robertson "said he had much the same reaction when the idea first came up but changed his mind after learning more," Estep writes. "Drug addicts will find needles and use drugs with or without a local needle-exchange program, but the program can help reduce the spread of expensive diseases, Robertson said."

Studies show that people who use exchanges are much more likely to get drug treatment, Estep notes. "Other studies have shown that exchange programs don’t encourage people to start taking drugs or increase how often users inject drugs; that they don’t increase crime; and that they help reduce the problem of drug users disposing of dirty needles improperly."

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The CDC said recently "that in 2015, Kentucky was among seven states where the incidence of new hepatitis C cases was more than twice the national rate," Estep reports. "Kentucky, West Virginia and Massachusetts had the highest rates, the May 12 report said. The problem has been building for years, according to the 2017 update to the Kentucky Department for Public Health’s state health assessment. The update, released in March, said Kentucky had the highest rate of new hepatitis C infections in the nation from 2008 through 2015, the last year with available data." Kentucky also has the second highest rate of babies born to mothers with the disease, trailing only West Virginia.

Those mothers need to be identified and treated before delivery, said Dr. Ardis Hoven, an infectious disease specialist with the state health department.“We have an epidemic, and we need to continue to deal with it,” she told Estep.

Treating hepatitis C is expensive, Estep notes: "In the last full fiscal year, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries, or $83,735 apiece, according to the Cabinet for Health and Family Services."

This week, Sen. Mitch McConnell can start making decisions about what Senate Republicans will put in their health bill

U.S. Sen. Mitch McConnell's role in the national health debate "will come into sharp relief this week," Burgess Everett and Jennifer Haberkorn report for Politico. "He will decide the contents of the Senate’s plan, most likely behind closed doors. And he is on the hook for getting something through a sharply divided Senate Republican Conference in the midst of an increasingly imperiled presidency."

The first shoe will drop Wednesday, when the Congressional Budget Office delivers "a highly anticipated report on the House health-care bill that is expected to show it would cause huge coverage losses," Politico notes. "That will provide a new round of ammunition to Obamacare supporters, even as it allows the Senate to truly start writing its own plan."

McConnell, who as majority leader named a 13-member working group to come up with the outlines of a bill, has been meeting with senators "without making substantive progress, according to attendees," Politico reports. "In the coming days, McConnell will have to move to break the impasse."

Sens. Lamar Alexander and Mitch McConnell (Getty Images)
The Kentuckian has given no clue to what he might do in concert with Sens. Lamar Alexander of Tennessee, Orrin Hatch of Utah and Mike Enzi of Wyoming, chairs of the key committees that will handle the bill publicly once it is drafted privately.

“Mitch right now is listening very carefully. He’s being very careful not to weigh in, thinking that this needs to come from the membership,” an unnamed GOP senator told Politico. “He’s not trying to force a particular point of view.”

"Only the faintest outline of a plan is taking shape," Politico reports. "Senators are working to make the House bill's tax credits more generous and to find a way to wind down Obamacare’s Medicaid expansion more slowly," instead of 2020. "The Senate is expected to repeal many Obamacare regulations but not go as far as the House did in rolling back protections for people with preexisting conditions." The House bill would give the states power to do that.

"The idea, according to several lawmakers, is that if the relatively ideologically diverse working group can agree to get behind a bill, that would get the GOP close to 50 votes," the point at which Vice President Mike Pence would break the tie in favor of Republicans. But it would be up to McConnell to get to 50, and that will be difficult.

“It’s pretty easy to put together 46 or 47,” said Sen. Roy Blunt (R-Mo.). “It’s getting to 50 that’s a challenge.” One obstacle may be Kentucky's other senator, Rand Paul, who is out of the Senate mainstream, saying the House bill didn't go far enough.

Senate Majority Whip John Cornyn of Texas said there will be a vote on the bill by late July, before the August recess, but "Some doubt that aggressive timeline," Politico reports. "Some Republican senators were privately hoping it would never reach this point. They would have preferred that the House bill fail, to spare them having to take up a measure they believe would cause too many people to lose insurance and do too little to lower premiums."

Kentucky's only Democratic member of Congress, Rep. John Yarmuth of Louisville, said recently that McConnell would not allow a health bill to come to a vote in the Senate, for fear of political repercussions in the 2018 elections. But Politico reports, "McConnell wants to have a vote on an Obamacare repeal bill, whether it passes or not, so the Senate can move on to tax reform and spending bills."

It would be unusual to bring a bill to a floor vote without a guarantee of passage, but that seems possible in this case. “We’re on a track to write a bill and vote on it,” Alexander told Politico; whether it will be successful, “I can’t say.”

Trump budget will include big cuts to Medicaid, maybe work rules

The detailed budget that the Trump administration will release Tuesday will contain big cuts to Medicaid, reflecting the approach of the health bill that House Republicans sent to the Senate this month, The Washington Post reports.

"Trump’s decision to include the Medicaid cuts is significant because it shows he is rejecting calls from a number of Senate Republicans not to reverse the expansion of Medicaid that President Barack Obama achieved as part of the [Patient Protection and] Affordable Care Act," Damian Paietta writes for the Post. "The House has voted to cut the Medicaid funding, but Senate Republicans have signaled they are likely to start from scratch."

"Trump offered a streamlined version of the budget plan in March, but it dealt only with the 30 percent of government spending that is appropriated each year," Paietta notes. "Tuesday’s budget will be more significant, because it will seek changes to entitlements — programs that are essentially on auto­pilot and don’t need annual authorization from Congress. The people describing the proposals spoke on the condition of anonymity because the budget had not been released publicly and the White House is closely guarding details."

The budget plan "also will call for giving states more flexibility to impose work requirements for people in different kinds of anti-poverty programs," Paietta reports. The story does not mention work requirements for Medicaid, but the opportunity for states to set such rules would not be a surprise, since it is in the House bill, and the proposed Medicaid plan for Kentucky includes them and was drafted by Seema Verna, the director of the Centers for Medicare and Medicaid Services.

National committee studying health impacts of surface coal mining in Central Appalachia to have first meeting in region Tuesday

A national committee studying the health impacts of surface coal mining in Central Appalachia will have its first public meeting in the region Tuesday, May 23 at Chief Logan State Park near Logan, W.Va.

The committee of the National Academies of Sciences, Engineering, and Medicine had a meeting in Washington on March 7, and has another one scheduled there for July 11. The site of a fourth meeting, set for Aug. 21, has not been announced. The study focuses on  West Virginia, Kentucky, Virginia and Tennessee.

At Tuesday's meeting, representatives from West Virginia Bureau for Public Health, the West Virginia Department of Environmental Protection, the West Virginia Coal Association and several environmental groups will participate in panel discussions form 12:45 to 3:45 p.m. From 6:30 to 9 p.m., a town hall meeting will allow community members will have an opportunity to address the committee. For a detailed agenda, click here.

The study is funded by a $1 million grant from the federal Office of Surface Mining Reclamation and Enforcement. It is examining research, primarily done by Indiana University's Michael Hendryx when he was at West Virginia University. Another study, by the National Institute of Environmental Health Sciences, is in process.

Saturday, May 20, 2017

Paul tells doctors and officials at Ashland hospital, a beneficiary of Medicaid expansion, that the country can't afford to keep it

Sen. Rand Paul at the hospital. (Daily Independent photo by Rachel Adkins)
The nation can't afford to continue the expansion of Medicaid, U.S. Sen. Rand Paul told doctors and officials Friday in Ashland at King's Daughters Hospital, which has benefited greatly from the expansion.

"We don't have any money; we have a printing press," said Paul, a Bowling Green eye surgeon. "And we borrow $500 billion a year. And there is the question: Could we ultimately destroy the country with that much debt? I call it the big-hearted, small-brain syndrome, which is very, very prevalent in Washington. They are sympathetic, they want to help people. We all do. But the thing is, if you destroy the country helping people, would you be better off or worse off?"

Before the Patient Protection and Affordable Care Act, Medicaid paid for "about 17 percent of patients in the King's Daughters Health System," Adam Beam reports for The Associated Press. Now that the law has added 470,000 Kentuckians to the rolls, "Medicaid pays for 23 percent of patients at the hospital system on the Kentucky-Ohio border."

The health bill sent to the Senate by the House would end the Medicaid expansion after 2020. Not having the expansion "would be the difference between staying open and not staying open," Chief Medical Officer Richard Ford told Beam.

King's Daughters' share of uninsured patients fell to 2 percent from 11 percent after Medicaid was expanded in 2014. "But despite the hospital's dependence on Medicaid, the amount of money the hospital made from each of those newly insured patients fell, too," Beam reports. "Ford says the system struggles to make a profit."

"It was more of a redistribution from one patient to the next more than it was helping us with covering our own expenses," Ford told him.

"Paul's solution to fix all of this is to make the health care system more market-based," Beam reports. "He wants to make it legal for people who don't get health insurance from their employer to join together with others in nationwide "health associations" to increase their bargaining power. Imagine, he said, if the National Rifle Association's more than 5 million members were able to join forces and negotiate with health insurance companies as a group instead of individually."

Garfield Grandison, a gastroenterologist, told Paul that he and other senators should consider more factors than cost. "Grandison and a local social worker said they’re concerned patients suffering from mental health and substance abuse problems could be hurt by the ACA replacement," because those would no longer have to be covered by health insurance, Andrew Adkins reports for the Ashland Daily Independent.

Paul said that would make premiums go down, and "said the fundamental question is based, for instance, on if a 72-year-old should be forced to pay for special procedures for others, such as pregnancy, in a free society," Adkins reports.

Grandison replied, "Should I be forced to drive on every single road my taxes pay for, or use every park my taxes help pay for? I understand from the standpoint of cost, where you’re going. You’ve made a good argument on cost, but there are other aspects that should be considered and part of the debate."

Study of Ind. Medicaid, proposed model for Ky., finds more than half of enrollees missed paying a premium and thus lost coverage

By Melissa Patrick
Kentucky Health News

Kentucky's plan to change Medicaid would require poor people to pay small, income-based premiums for coverage. That creates a barrier to health care, says a study of Indiana's similar plan allowed by a federal waiver.

“During the first 21 months of the waiver program, 324,840 (55 percent) of the 590,315 people eligible to pay didn’t make a required payment at some point. All of them were then kicked off of Medicaid or were left with inferior coverage," the liberal-leaning Kentucky Center for Economic Policy said on its policy blog.

Indiana's program requires enrollees to pay between $1 and $100 a month, depending on income, to participate in the plan with the most benefits, including dental and vision. This is the only plan available to Hoosiers above the federal poverty line.

If the enrollees fail to make a payment, those above the poverty line are disenrolled and locked out of the program for six months, while those in poverty are moved to a more limited plan that requires co-payments for all services, has lower service limits and limited drug benefits, and does not include dental and vision benefits.

Under Kentucky's proposed waiver, those who fail to pay would face a six-month lockout unless they pay back three months' worth of premiums and take a financial or health literacy class. Kentucky's plan does not include dental or vision benefits, though these benefits can be earned through a rewards program. This plan is expected to be approved in June, and to go into effect Jan. 1.

Kentucky's plan is modeled after Indiana's. Both were designed by Seema Verma, the new administrator for the Centers for Medicare and Medicaid Services. She has recused herself from the decision on Kentucky's plan, but it's expected that under her leadership other states will be allowed to impose similar monthly fees.

The proposed premium requirements in Kentucky's waiver plan, called Kentucky HEALTH, are based on income and the length of time a person is enrolled, if above the poverty line.

Premiums would be $1 to $15 per month, based on income, and would rise in incremental limits for those above the poverty line after the second year to a limit of $37.50. The federal poverty line for an individual is annual income of $12,060.

The Indiana plan, which took effect in 2015, was evaluated by the Lewin Group, a health-care consulting firm, using almost two years of data.

Among the 55 percent who had missed a premium payment, most (57 percent) were at or below the poverty level, which allowed them to drop to the lower-tier plan instead of being locked out.

"We can expect large numbers of Kentuckians to be left without coverage if the waiver is approved by the federal Department of Health and Human Services," KCEP said. "The assessment of the Indiana waiver confirms that both the cost and process of paying premiums is a barrier to coverage for low-income people."

The report, which was limited to Indiana, and the KCEP did not estimate how many Kentuckians might regain coverage by getting premiums up to date and taking a health or financial literacy course.

The report found that almost half of those who were kicked off the Indiana program or never made an initial payment did have insurance, mostly through an employer, "but that means that 53 to 59 percent were without health-care coverage of any kind," said KCEP.

The most common reasons enrollees gave for not paying premiums were that couldn't afford it, they were confused about the payment process, or didn't know they were required to make a payment.

The report also looked at access to care and found that people who were kicked off coverage or never enrolled were less likely to make appointments for care or fill a prescription in the previous six months.

Kentucky's plan is expected to save $2.2 billion over the next five years, of which the state's portion would be $331 million, according to the state's waiver request. It estimates that after five years, the state's Medicaid rolls would have 86,000 fewer people than an unchanged program would have. About 30,000 people a month go on and off Medicaid in Kentucky as their circumstances and incomes change.

Beshear joins lawsuit to defend Obamacare cost-sharing subsidies; D.C. appeals court to consider request Monday

By Melissa Patrick
Kentucky Health News

Kentucky Attorney General Andy Beshear and 15 of his counterparts have filed a motion aimed at maintaining cost-sharing subsidies for health insurance for low-income people under the Patient Protection and Affordable Care Act. The attorneys general want a federal court to let them directly defend the subsidies, about which the Trump administration has been ambivalent.

In 2014, House Republicans sued the Obama administration over the legality of these cost-sharing subsidies being paid to insurance companies because Congress never appropriated the funding for them. A district court ruled in favor of the House, but the Obama administration appealed the ruling. The subsidies were allowed to continue pending the appeal.

When Obama left office, the Trump administration became the defendant in the lawsuit. The administration is scheduled to inform the U.S. Court of Appeals for the District of Columbia Circuit on Monday, May 22, how it wants to proceed with the appeal.

Harris Meyer of Modern Healthcare reports, "The state attorneys general claim their states' interests would be gravely harmed if the payments stop because many insurers would exit the individual insurance market, premiums would spike, many of their residents would be left uninsured, and state and local governments would face heavy costs in paying for medical care for the newly uninsured people."

Beshear said in a news release, “Thousands of Kentuckians who purchase health insurance from the federal exchange are at risk of losing access to affordable health care coverage. The loss of federal funds and the financial uncertainty threatened by the case would lead to higher health insurance costs for Kentuckians and to insurers abandoning the individual health insurance market.”

The Kaiser Family Foundation projects that without the cost-sharing subsidies, premiums would increase by an average of 19 percent on ACA "silver" plans, the most popular, and higher in states that have not expanded Medicaid. The subsidies are available to people with incomes between 100 and 250 percent of the federal poverty level -- between $24,300 and $60,750 for a family of four.

Kentucky has extended its deadline for filing 2018 Obamacare plans to June 7, from the original May 17, "to allow insurers more time to obtain relevant data, including enrollment and claims data for the beginning of 2017, for use in developing assumptions utilized by actuaries to determine necessary plan pricing," Ronda Sloan, spokeswoman for the state Department of Insurance, told Kentucky Health News in April.

During the 2017 open enrollment period, 81,155 Kentuckians enrolled for coverage through the exchange and four out of five of them received a subsidy to help pay for their premiums, according to the Kentucky Center for Economic Policy. 

Both the ACA and the House-passed health bill, called the American Health Care Act, include subsidies, but use different formulas. The ACA takes family income, local cost of insurance and age into account, while the AHCA bases its tax credit only on age, with a phase-out for individuals with incomes above $75,000. It would continue the cost-sharing subsidies until 2020, "but would not appropriate those funds, leaving insurers uncertain whether they would receive the payments," Modern Healthcare reports.

Subsidies to low-income consumers who sign up for insurance on the exchange are estimated at $7 billion this year, according to the Congressional Budget Office.

Politico reports that Trump has told his advisers that he wants to end the Obamacare subsidies to force Democrats to the table to negotiate an Obamacare replacement.

The states seeking to intervene in the case are California, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, New York, Pennsylvania, Vermont and Washington, as well as the District of Columbia.

Friday, May 19, 2017

Second town in tobacco-loving Grayson County goes smoke-free; local Population Health Committee's efforts helped

Clarkson, in Grayson County (Wikipedia map)
By Melissa Patrick
Kentucky Health News

Two of the three towns in Grayson County now have smoke-free ordinances, partly as a result of a campaign led by the CEO of the local hospital.

Clarkson, with an estimated population of 900, became the second city in the county of 26,000 to enact a city-wide smoking ban. Leitchfield, the county seat, population 6,900, became smoke-free Jan. 1.

The Clarkson City Commission approved the ordinance by a 3-2 vote at a special called meeting May 1, Theresa Armstrong reports for the Grayson County News-Gazette.

Twin Lakes Regional Medical Center CEO Wayne Meriwether, a smoke-free advocate who leads a local Population Health Committee, said in a telephone interview that Clarkson's ordinance will take effect immediately and is stronger than Leitchfield's ordinance because it not only includes all public places, as Leitchfield's does, but also workplaces.

“Those commissioners that were in favor of it . . . wanted to send a message that their community was progressive and that they wanted to do what was in the best health interest of their community. So they took a strong stance on it,” Meriwether said.

Clarkson Commissioner Ed Schott voiced concern at the meeting about the distance smokers must stand from an establishment's door under the ordinance, Armstrong reports. “The front porch of the funeral home is not 15 feet from the door in any direction, and, at the ball field, the concession stand is not 15 feet away,” Schott said. “I would like us to remove this restriction from the ordinance.”

Schott and Mayor Bonnie Henderson, at the March 13 meeting, told the commissioners that the general consensus of the city's local businesses was that most of them were already smoke-free, but didn't want a law telling them how to run their businesses, Armstrong reported in March.

Despite these concerns, the ordinance passed. Schott, who originally supported the ordinance, and Henderson, who had always opposed it, voted against it; Commissioners Bob Vincent, Joyce Bell and Kay Gibson voted in favor of it.

The Population Health Committee, which is made up of representatives from the hospital, local schools, the health department, city government, local industries and other interested citizens, has led smoke-free efforts in Grayson County, where tobacco was once the main cash crop and its heritage remains strong. The county's estimated smoking rate is 34 percent; the state rate is 27 percent.

Initially the committee worked to pass a countywide ban, but that effort died last year for lack of a second reading in the Grayson County Fiscal Court, despite strong local support and a survey that found 82 percent of the people in the county wanted it.

Meriwether said the committee decided to advocate for smoke-free laws "community by community" after the county-ban failed. Caneyville, estimated population 620, is the only incorporated community left in Grayson that hasn't passed a ban.

“That's been the goal all along: Leitchfield, Clarkson and then Caneyville,” Meriwether said. “That would be the biggest part of our county, if we can get all three communities to have ordinances.”

He added, “We have their packets all ready!” The committee has prepared information packets that include facts about the dangers of second-hand-smoke and the results from the countywide survey.

Hospital CEO Wayne Meriwether and Ellen Hahn, director
of the Kentucky Center for Smoke-Free Policy (UKNow photo)
Leitchfield and Meriwether were recently honored at the Kentucky Center for Smoke-Free Policy's annual conference for their efforts in promoting smoke-free workplaces.

Leitchfield city leaders were presented with the "Smoke-Free Indoor Air Endeavor" award and Meriwether was honored with the "2017 Lee T. Todd, Jr. Smoke-free Hero" award for his advocacy of smoke-free ordinances and getting rural hospitals to push for them, reports the News-Gazette.

“I was really happy to see Leitchfield was recognized," he said. "It took a lot of courage for them to be the first one and their city council took some heat, but they did the right thing and they listened to their constituents that wanted it, which was the majority of them.

“And I appreciated getting an award, but that really should go to all of our Population Health Committee members and others that advocated for the ordinance -- a lot of people did.” he said.

Meriwether said his interest in the subject was spurred by concern for children. “We moved from Leitchfield from Henderson, Kentucky, about five years ago. . . . Henderson went smoke-free about 10 to 12 years ago and my children had, didn't remember any place where people smoke. The first restaurant we went to when we moved to Leitchfield, we walked in, and my daughter said, 'What's that smell?' And I said, well, they allow smoking in here. And she said, 'I didn't think anyplace allowed smoking.'

“The point is, in just a few years you can make such a difference and change so many lives. So my kids were never exposed to cigarettes, they weren't allowed anyplace, and so they both grew up as nonsmokers. And that is the kind of effect an ordinance can have.”

The Population Health Committee came out of the hospital's Community Health Needs Assessment, which is required every three years under the Patient Protection and Affordable Care Act.

In addition to its smoke-free advocacy work, the committee actively works on initiatives around nutrition and obesity, increasing opportunities for physical activity and improving community awareness about health and wellness.

"We felt like it was a responsibility for us to try to make a difference," Meriwether said of the committee. "I think it is a real model for hospitals to follow to try to make a difference in the communities that they serve."

He stressed the importance of community partnerships to improve the health of its citizens.

"We may have initiated the committee," he said. "but it takes a lot of people to make a difference."

Thursday, May 18, 2017

Low-income adults in Medicaid expansion in Kentucky and Arkansas report better health and medical care, study finds

By Melissa Patrick
Kentucky Health News

Two states that expanded Medicaid through the Patient Protection and Affordable Care Act showed a 41 percent increase in the number of enrollees with a regular health-care provider and a 23 percent increase in the share who report excellent health, according to a three-year study of Kentucky and Arkansas.

The study also found that low-income adults with chronic diseases in the two states were more likely to report that they had better health, were getting regular care and were able to afford their medications.

Kentucky and Arkansas and Kentucky both expanded Medicaid to people who earn up to 138 percent of the federal poverty line, but in different ways. Kentucky expanded Medicaid while Arkansas used federal Medicaid funding to provide private insurance to its low-income adults. The study compared them to Texas, which did not expand the program.

The report said that while Arkansas and Kentucky took different approaches to Medicaid expansion, the benefits to enrollees were nearly equal between the states.

“The Affordable Care Act is leading to substantial improvements in health care for low-income adults in Arkansas and Kentucky, and people report that their health is better too,” Dr. Benjamin Sommers, lead author of the study, said in a news release. “In contrast, many low-income adults in Texas continue to lack insurance and more frequently have to skip needed health care due to cost concerns.”

The study, published in Health Affairs, found that when compared to Texas, enrollees in Kentucky and Arkansas reported "substantially" better health, fewer emergency-room visits, increased access to care and medications, and cost savings.

                                                        graphic from report 
Kentucky has 1.4 million people on Medicaid, with 470,000 of them covered through the expansion. As of Jan. 1, Arkansas had 310,951 low-income people enrolled on its "private option" plan funded by Medicaid.

Not surprisingly, low-income adults in Arkansas and Kentucky were much more likely to have health coverage than their counterparts in Texas. Researchers found that by the end of 2016, the percentage of people in Arkansas and Kentucky without coverage had dropped 20 percentage points more than in Texas. In 2016, the uninsured rates were 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas.

The study found that low-income adults who had gained coverage in Arkansas and Kentucky under the ACA had:
  • A 41-percentage-point increase in having a usual source of health care
  • A 58.6-point drop in reports of trouble paying medical bills
  • A 74.7-point decline in skipping needed health care because of costs
  • A 28-point drop in the likelihood of having an emergency-room visit
  • A 23-point increase in the share who reported they were in excellent health
  • $337 less in medical out-of-pocket spending per year
It found similar results among low-income adults with chronic illnesses who had gained coverage under the ACA, including:
  • 56 percentage points more likely to report having regular care for their chronic condition than were chronically ill adults in Texas
  • 51 points less likely than those in Texas to skip medications due to cost
  • 20 points more likely to report being in excellent health
The study was conducted by the Harvard T.H. Chan School of Public Health. It surveyed a random sample of 10,885 adults aged 19 to 64 in November and December from 2013 to 2016 via land lines and cell phones. The study includes a demographic breakdown of the full samples in each state.

“This study, along with others, makes it clear that the Affordable Care Act’s Medicaid expansion has helped states make substantial gains in coverage while ensuring people can get and afford the health care they need,” said Dr. David Blumenthal, president of The Commonwealth Fund, which funded the study. “Repeal efforts that end the expansion threaten the health and financial security of the 12 million people nationwide who benefited from it. We must hold on to these gains and continue to work toward affordable and accessible health care for everyone.”

The House-passed health bill, called the American Health Care Act, would largely phase out the Medicaid expansion and limit federal funding of the program, reducing federal spending on it by an estimated 24 percent over 10 years. If people enrolled in the expansion went off it, they could not get back on. About 30,000 Kentuckians a month go on and off Medicaid.

Gov. Matt Bevin has said Kentucky can't afford to pay for its share of the expansion costs (5 percent this year, rising to the ACA's 10 percent limit in 2020) and has applied for a waiver that would let the state charge small, income-based premiums and would require "able-bodied" recipients to either work, volunteer, go to class or take job training, among other things.

The waiver request estimates that the changes would make the state's Medicaid rolls have 86,000 fewer people in five years than without the waiver. The waiver is expected to be approved in June and to go into effect Jan. 1.

Tuesday, May 16, 2017

Liberal-leaning group says that if Senate passes House health bill, or big parts of it, results will be dire for millions in rural America

People who have health insurance through the Medicaid expansion are at great risk of losing their coverage if the Senate passes the House health bill, a decision that would greatly harm rural America, says a Center on Budget and Policy Priorities report.

Republican senators have said they are "starting from scratch" and writing their own bill, but that is misleading, said Shannon Buckingham, spokesperson for the liberal-leaning group. "Make no mistake, the House bill's core provisions remain firmly at the center of Senate discussion."

Nearly 1.7 million rural Americans have health insurance through the Patient Protection and Affordable Care Act's expansion of Medicaid to those who earn up to 138 percent of the federal poverty line, about $33,000 for a family of four. Of the 470,000 who have coverage through the expansion in Kentucky, an estimated 224,000 are in rural areas.

The report says the House health bill, called the American Health Care Act, would "effectively end" the Medicaid expansion because "beginning in 2020, states would receive only the regular federal Medicaid matching rate . . . for any new enrollees under the expansion instead of the permanent expansion matching rate of 90 percent." The matching rate for Kentucky is 70 percent, so the state would have to pay 2.8 times more than under current law for each new enrollee, the report said.The bill also allows states to stop enrolling people in expanded Medicaid.

For people who don't qualify for Medicaid, the House bill would raise health-care costs by reducing tax credits that help low income people pay for premiums and out-of-pocket costs; would allow states to take away protections for pre-existing conditions; and cut taxes by more than $600 billion over 10 years, mostly for the top 1 percent of income earners.

The detailed CBPP report, which offers state-level details on many measures, found that in at least eight expansion states, including Kentucky, more than one-third of expansion enrollees live in rural areas.

Gov. Matt Bevin has said Kentucky can't afford to pay for its expansion population and has applied for a waiver that would let the state charge small, income-based premiums and would require "able-bodied" recipients to either work, volunteer or take job training, among other things. These changes are expected to make the state's Medicaid rolls have 86,000 fewer people in five years than they would otherwise. The waiver is expected to be approved in June and to go into effect Jan. 1.

The report notes that states that expanded Medicaid had the largest drops in rural people without health coverage, from 16 percent in 2013 to 9 percent in 2015. In non-expansion states, the uninsured rate dropped from 19 percent to 15 percent in 2015. Kentucky's uninsured rate dropped to 7.5 percent from 20.4 percent.

"While those numbers may seem abstract, they have tangible impacts on access to care, on health and to financial security," Mary Wakefield, former acting deputy secretary for the U.S. Department of Health and Human Services, said. For example, she said the rural states of Kentucky and Arkansas, which expanded Medicaid, saw a "one-third increase in the share of low-income adults getting regular check-ups and a two-thirds decrease in the share depending on the emergency room for care."

The report adds, "In Kentucky, state data show tens of thousands of low-income individuals have received cholesterol, diabetes and cancer screenings, and preventive dental services," as a result of expanding Medicaid.

Wakefield said Medicaid expansion has reduced people's risk of medical bankruptcy, improved treatment access for people with substance use disorders and dramatically decreased uncompensated care in rural hospitals.

"The House health bill is a threat to rural hospitals," said Jesse Cross-Call, a senior policy analyst at CBPP and co-author of the report. "Over the past few years, closures of rural hospitals around the country have been heavily concentrated in states that have not expanded Medicaid,"

The report says, "Most of the 78 rural hospitals that have closed since 2010 are in Southern states that haven't expanded Medicaid" and "uncompensated care costs as a share of hospital operating budgets fell by about half between 2013 and 2015 in expansion states."

The House bill would partially restore the Disproportionate Share Hospital payments that helped rural hospitals make up for the uncompensated care before Medicaid was expanded," but that would fall "far short of the revenues hospitals would lose," according to the American Hospital Association and others, said Aviva Aron-Dine a senior fellow at CBPP.

Cross-Call added that the expansion had created a "pathway to health coverage where before the ACA one often did not exist," noting that people who live in rural areas often have lower incomes, have more contract work and are less likely to have an employer that offers health coverage, than non-rural areas.

Tara Straw, senior policy analyst at CBPP and co-author of the report, said rural Americans will be harmed if the new health plan removes the ACAs "generous and flexible" tax credits and replaces them with credits that would be worth much less.

Straw said ACA tax credits are often higher in rural areas because the cost of insurance tends to be higher, due to low population density, a limited number of providers and little competition among insurers. She also noted that people who live in rural areas tend to be older and have lower incomes.

"Because the ACA's credit is based on the cost of an actual plan, and not a fixed dollar amount, it helps protect people from premium increases," she said. For example, the AHCA tax credit for a West Virginia enrollee would be less than half of what an ACA credit would be, $7,400 compared to $3,100, for a plan that covers less, she said.

The House bill would provide a flat tax credit varying only by age: $2,000 for people under 30; $2,500 for people age 30 to 39; $3,000 for people age 40 to 49; $3,500 for people age 50 to 59; and $4,000 for people age 60 and older.

Straw explained that while the House bill allows for a tax credit for a 60 year old to be twice as high as for a young adult, it also allows older adults to be charged five times as much.

The House bill would also repeal the ACA's cost-sharing subsidies, which are available to people with incomes below 250 percent of the poverty line and allow them to purchase coverage with lower deductibles and covers other out-of-pocket costs.

McConnell says all Senate Republicans are working on health bill, invites Democrats to join them

McConnell used a graphic on the floor to drive home his point.
Senate Majority Leader Mitch McConnell said Tuesday that all Republican senators are working on a health bill, and invited Democrats to help them.

“Can our Democratic colleagues, who promised more choice under Obamacare, really be okay with the continuing failures of Obamacare? The status quo under Obamacare is simply unsustainable and unacceptable,” McConnell said in a speech on the Senate floor. “That’s why the entire Senate Republican Conference is working together on the best way forward to bring much-needed relief to the families who’ve been left behind by Obamacare’s continuing failures. I hope our Democratic colleagues will join us in working to do so. They just sent me a letter last week where they acknowledged that Obamacare hasn’t lived up to its promises and where they effectively conceded that the status quo is unsustainable.”

McConnell recently appointed a working group of 13 Republican senators to work on a health bill and was criticized because they were all men. Since then, he has said no senator will be left out of the drafting process. Last week Democratic Rep. John Yarmuth of Louisville said McConnell wouldn't let a health bill come to a vote before the 2018 elections for fear of political damage.

Click on the chart to view a larger version of it.
McConnell prefaced his remarks by citing the headline on the latest Gallup poll, taken May 3-7: "Health care surges as top problem in U.S." The story said, "Americans became much more concerned about health care this month, with 18 percent naming it as the most important problem facing the U.S. Mentions of health care tie with mentions of 'dissatisfaction with government/poor leadership' at the top of the most-important-problems list. This is the highest percentage mentioning healthcare since November 2013, amid the troubled rollout of the government healthcare exchanges."

Gallup chart of top problems in poll during the last three months
McConnell said, "It’s not hard to see why so many Americans feel this way. They turn on the TV and hear that there will be even fewer options on the Obamacare marketplaces in state after state. They pick up the newspaper and see that even more double-digit premium increases are being proposed for too many of the Obamacare plan options that still remain. . . . It’s troubling news, especially given that so many states, like mine, have already experienced insurers fleeing the Obamacare marketplace leaving families with limited options. This year . . . 49 percent, nearly half of the counties in Kentucky, have only one insurer to choose from. And of course, having only one option is really no choice at all."

McConnell said nothing in his speech about Medicaid, the expansion of which under Obamacare covers about 470,000 Kentuckians, according to the latest figures from the Cabinet for Health and Family Services. About 80,000 people in Kentucky are covered by private Obamacare policies.

Foundation's $3 million program is helping seven counties become healthier in several ways, independent evaluation says

A initiative focused on children's health is helping the Foundation for a Healthy Kentucky change community policies and environments, improve physical activity and nutrition, and strengthen health coalitions in seven Kentucky communities, according to an independent evaluation released by the foundation today.

The grants in the five-year, $3 million "Investing in Kentucky's Future" initiative are also providing useful lessons for place-based grantmakers, said the evaluation by the Center for Community Health and Evaluation, a research center of the Kaiser Permanente Washington Health Research Institute.

The initiative is aimed at reducing the risk that today's school-aged children will develop chronic disease later in life. It has made matching grants for community health coalitions in Breathitt, Clinton, Grant, Jefferson, McCracken, McLean, and Perry counties. All are focused on preventing and reducing childhood obesity except the Louisville coalition, which is working to foster resiliency in children facing traumatic events and other experiences that can lead to toxic stress in childhood and chronic health conditions in adulthood.

"The real value of the Investing in Kentucky's Future initiative is that it's fostering the ability of these seven Kentucky communities to keep improving their residents' health long after the grant period ends," Charlie Ross, chair of the foundation's board of directors, said in a news release. "Yes, the grants have helped build some beautiful walking trails and playgrounds and ensure healthier foods at park concessions, but they've also created lasting partnerships, changed school and community policies, and developed the skills of a cross-sector coalition of people committed to making a healthier future for their children."

The evaluation listed five lessons from the initiative:
  1. Community-Driven Grant Approach: Allowing community health coalitions to study and determine their own health priorities and the solutions they would employ is leading to greater grantee engagement, but also to more diverse strategies.
  2. Coalition Approach: Requiring grantees to use or create a coalition of partners from a variety of sectors is helping build community support for the work. School engagement has been particularly important for the initiative, which focuses on school-aged children.
  3. Planning Phase to Promote Equity: Recognizing that communities have various levels of ability to compete for and implement grant programs, the foundation included funding for a required a planning phase during which grantees would develop a structured business plan to address their selected issue. The planning phase made the grant more accessible to communities with fewer resources.
  4. Sustainability Elements: Grant requirements that were focused on sustainability ─ the planning phase, a 50 percent cash match, a focus on changing policies in the community, and an evaluation ─ have given coalition members skills and experience to them continue to improve the health of their communities.
  5. Shorter-Term Evaluation Measures: The foundation recognized that significant changes in complex health issues take more than five years to see, so it focused its evaluation on shorter-term changes that have been proven to lead to longer-term health improvements.
Investing in Kentucky's Future is entering its fourth year, but some communities' grants will extend into 2019 because they started later than others. The grantees are: Partnership for a Healthy McLean County, Purchase Area Connections for Health (McCracken County), Fitness for Life Around Grant County, Breathitt County Health Planning Council for Children, Perry County Wellness Coalition, Clinton County Healthy Hometown Coalition, and the Bounce Coalition (Jefferson County).

A copy of the evaluation, "Toward a Healthier Kentucky: Lesson Learned from Evaluating Place-Based Community Health Improvement," is available here