Monday, July 24, 2017

Annual Bost Health Policy Forum to be held in Lexington Sept. 25; focus will be on "Kentucky's Substance Use Crisis"

The 2017 Howard L. Bost Health Policy Forum, "Kentucky's Substance Use Crisis: Solutions and Strategies" will have as its keynote speaker Sam Quinones, author of the book Dreamland, which chronicles the rise of prescription opioid abuse and subsequent addiction across the nation. Much of the book focuses on Portsmouth, Ohio, just across the river from Kentucky.

"Quinones' narrative is a compelling account of the opioid crisis that took 1,400 lives in Kentucky last year," Ben Chandler, Foundation for a Healthy Kentucky president and CEO, said in the news release. "Kentucky's experience with both prescription and illicit opioids has been more severe and longer-lived than in most other states. Quinones and other presenters will help us better understand how we got to where we are today, how to climb our way out of this crisis, and the policy changes that can prevent this from happening again."

The annual forum is sponsored by the foundation with support from Gilead Sciences Inc., a research-based bio- pharmaceutical company, in memory of Dr. Howard L. Bost, who helped create Medicare and Medicaid, developed the Appalachian Regional Hospital system, improved mental-health services in Kentucky and created the vision for the foundation.

It will be held at the Marriott Griffin Gate Resort in Lexington on Monday, Sept 25. Attendance is free, but registration is required. Click here to register.

The forum will also feature a series of TED-style talks and afternoon breakout sessions that will explore where Kentucky stands related to the opioid epidemic; how evidence-based policy can work as a tool to address the social, economic and health impacts of opioid addiction; and prevention and intervention strategies.

Interactive map gives estimated premiums under latest Senate health-insurance bill, by age, income and county

The fate of health-insurance legislation in the Senate remains very much up in the air, but the Kaiser Family Foundation has updated its interactive, county-level map showing how the latest version of the Better Care Reconciliation Act would affect premiums for silver-level Obamacare plans, the type most commonly purchased with tax-credit subsidies. The figures are the estimated premium in 2020 after tax credits. Pop-up tables for each county also show premiums for cheaper bronze-level plans, the amounts of tax credits (or savings from putting pre-tax income into health-savings accounts), and the change from current law. Here's a screenshot of the map for a 40-year-old Kentuckian with a yearly income of $40,000:

The map can be adjusted for age (27, 40 and 60) and income (mostly in in $10,000 increments). The version above is for 40-year-olds with income of $40,000 a year. Here's one for 60-year-olds making $60,000, showing that premiums for them would go up in every county:

To show how the individual county estimates are displayed, here's a screenshot of estimates for a 40-year-old with $40,000 annual income in Grayson County (click on it for a larger version):

Nursing professor at Pikeville moves up to dean

Karen Damron
Karen Damron, an associate professor in the Elliott School of Nursing at the University of Pikeville, is the new dean of the school.

Damron was raised in El Paso moving to Pikeville in 1993, and has taught full-time at the university since 1998, a news release said. Before becoming an educator, Damron worked full-time as an RN in obstetrics and neonatal intensive care in hospitals in Texas and Maine. She earned her Ph.D. from the University of Kentucky, an M.S. from Bellarmine University and a B.S. from the University of Texas at El Paso, all in nursing. She and her husband, Larry, live in Pikeville and have four sons and three grandchildren.

In 2010, the Mellon Foundations named Damron a fellow to the Salzburg Seminar in Austria. She earned UPike’s William Wade and Helen Record Walker Teaching Excellence Award in 2014 and was awarded a pre-doctoral faculty fellowship by the Appalachian College Association for the 2015-2016 academic year. Her research interests include perinatal smoking and factors that impact a woman’s smoking status in pregnancy.

Sunday, July 23, 2017

As health-insurance vote looms, McConnell's path to immediate success is narrowed, and Paul remains unwilling to follow him

Kentucky Health News

As Senate Majority Leader Mitch McConnell moved toward a climactic vote Tuesday on health insurance, the Senate parliamentarian made it more difficult for him to maneuver by saying that some measures would require more votes to pass.

Sen. Mitch McConnell (Photo
by Brendan Smialowski, Agence
via Getty Images)
McConnell is trying to pass a bill under budget-reconciliation rules, which disallow the filibusters that require 60 votes to stop. His goal is 50 votes and a tie-breaking vote by Vice President Mike Pence. But the parliamentarian has ruled that several points don't qualify under reconciliation because they aren't related to the budget, taxes or spending.

"In a blow to the insurance industry, the parliamentarian has advised that two key market-stabilization provisions in the bill would be against the rules," Nathaniel Weixel of The Hill reports. "First, the legislation can't appropriate the cost-sharing reduction subsidies insurers rely on to keep premiums and deductibles low; it can only repeal them. Additionally, a 'lockout' provision requiring consumers with a break in coverage to wait six months before buying insurance also violates the rules, according to the guidance." Also nixed was a repeal of the law limiting insurance company profits.

The cost-sharing subsidies have been in doubt because Congress has not specifically appropriated money for them, and the Trump administration has suggested that it might stop them -- a move that could further destabilize insurance markets.

Other provisions found wanting "include policies important to conservatives, such as restrictions on tax credits being used for insurance plans that cover abortion," The Hill reports. "Language in the bill defunding Planned Parenthood for a year also violates budget rules, according to the parliamentarian. That guidance is sure to anger anti-abortion groups who backed the bill specifically because of those provisions."

McConnell could revise the language to get it approved, or conservatives could ask the Senate to overrule the parliamentarian, but in the past McConnell has thrown cold water on that idea.

"The parliamentarian has also not yet ruled on a controversial amendment from Sen. Ted Cruz (R-Texas) that would allow insurers to sell plans that do not meet Obamacare regulations," The Hill reports. "If that provision were struck, conservative support for the bill would be in doubt."

The parliamentarian could also complicate any McConnell efforts to get votes by inserting special funding that would help states represented by holdout senators.

American Health Policy Institute President Tevi Troy, a former deputy HHS secretary in the George W. Bush administration, told The Wall Street Journal that Republican leaders' work on the legislation is "entirely political," about what can get enough votes to pass, not about what the best policy would be. 

It remains unclear whether McConnell can even get the votes to take up a bill, much less pass anything resembling the one he has been trying to pass without success.

Sen. Rand Paul (Getty Images)
His more conservative Kentucky seatmate, Rand Paul, said on CNN's "State of the Nation" Sunday that he would not vote to take up McConnell's bill, which he called a "monstrosity" with a "pork fest" of subsidies for insurance companies.

Paul said he would vote to take up a "clean repeal" bill, which McConnell has offered as an alternative. That measure would not become effective for two years, giving Congress time to figure out a replacement for the 2010 Patient Protection and Affordable Care Act.

Either bill could be a vehicle to pass something different, perhaps even a limited, bipartisan measure to stabilize insurance markets. McConnell said last month that would be the alternative if Republicans couldn't pass a bill on their own, but more recently has cast doubt on that option.

"In the absence of internal consensus on health reform, other GOP lawmakers are leaning toward a more bipartisan approach," Brianne Ehley reports for Politico.

McConnell told reporters at the White House following a lunch with President Donald Trump and almost all of the Republican senators, "I think we have two options here. I think we all agree it's better to both repeal and replace. But we could have a vote on either, and if we end up voting on repeal only, it will be fully amendable on the Senate floor and if it were to pass without any amendment at all there's a two-year delay before it kicks in . . . so the takeaway from what I'm telling you is no harm is done from getting on the bill."

If no bill is taken up, "We’ll go back to the drawing board and get a bill up,” Senate Republican Conference Chair John Thune of South Dakota said on "Fox News Sunday." “We are going to vote to repeal and replace Obamacare. It’s not a question of if, it’s a question of when.”

Paul agreed, telling CNN's Jake Tapper, “We can do this for quite a while.”

Meanwhile, Trump criticized Paul for his frequent TV appearances. Privately, White House officials criticized McConnell for not getting the votes for a bill that Trump and Republicans have long promised, while Republican senators "say Trump failed to provide any meaningful political momentum for the prized measure," Alex Bolton reports for The Hill. "Tensions between Trump and Senate Republicans have been a theme of the months-long effort to win passage of the healthcare legislation." Trump has been sending mixed messages lately, The Associated Press reports.

McConnell "is getting pummeled in the press," Fox News media reporter Howard Kurtz writes, rounding up much of the critical coverage and commentary. But he says McConnell "was essentially put in an impossible position" that even "Master of the Senate" Lyndon B. Johnson couldn't have played well.

"I doubt that even LBJ, in his Senate arm-twisting days, could have pushed through a bill so unpopular with the public and such anathema to two competing factions," Kurtz writes. "It’s easy to blame tactics when everyone does their tick-tocks, and the Kentucky senator may have made some missteps. But the bill ultimately failed because of the substance: it was too weak at changing Obamacare for the most conservative GOP senators and too draconian in reducing coverage for the most moderate ones. And the majority, with 52 members, could afford to lose just two votes against united Democratic opposition. . . . There’s a reason the Republicans don’t have the votes, and it’s not Mitch McConnell."

Protesters ramp up activity against state's only remaining abortion clinic, prompting national news coverage

Protesters at clinic (AP photo by Dylan Lovan)
The battles over Kentucky's only remaining abortion clinic have prompted national stories about the prospect that the state could become the only one with no place to get a legal abortion.

"Both sides in the abortion fight raging in Kentucky agree on one thing: The stakes are as high as ever," reports Bruce Schreiner, a Louisville-based writer for The Associated Press. He details Republican Gov. Matt Bevin's "licensing fight" with EMW Women's Surgical Center in Louisville and the start of organized protests there by Operation Save America, "a Christian fundamentalist group."

"The group's leaders state their purpose unequivocally: to rid Kentucky of its last abortion clinic," Schreiner reports. "Some of the group's followers were arrested during a protest outside EMW in the spring. The group has said it won't use those same tactics in the coming days, but a federal judge on Friday ordered the creation of a 'buffer zone' to keep protesters out of an area in front of the clinic. The pre-emptive move was requested by federal prosecutors to prevent protesters from blocking access to the surgical center."

Anna Werner of  CBS News reports that the group plans to protest at "other locations, including the doctors' homes." The clinic has been the scene of protests since soon after it opened in the early 1980s, but "We have never been under siege like this," Dr. Ernest Marshall, a co-founder of the clinic, told AP. "We have never had any question as to whether we would exist."

Saturday, July 22, 2017

Study: 33% of dementia cases could be prevented by avoiding certain risk factors, including 9% by reducing mid-life hearing loss

By Melissa Patrick
Kentucky Health News

One-third of the world's dementia cases might be prevented if people avoided nine very different risk factors in three stages of life, according to experts speaking at the 2017 Alzheimer's Association International Conference.

The factors, by age group, are: going to school beyond age 15; managing high blood pressure, obesity and (this was something new) hearing loss between 45 and 65; and reducing smoking, depression, physical inactivity, diabetes and social isolation in later life.

The researchers said resolving those factors could reduce dementia cases by 33 percent. In comparison, they said that finding a way to eliminate the major genetic risk factor for dementia, called apolipoprotein E (ApoE), would prevent only 7 percent of cases.

The study, published in The Lancet, the leading British medical journal, brought together 24 international experts to review existing research. They presented their findings at the Alzheimer's conference in London, England, Robert Preidt reports for HealthDay.

"Acting now will vastly improve life for people with dementia and their families, and in doing so, will transform the future of society," lead author Gill Livingston, a professor at University College London, said in a news release.

About 47 million people have dementia, and the number is estimated to nearly triple by 2050.  An estimated 69,000 Kentuckians were diagnosed with Alzheimer's disease in 2016, according to the Alzheimer's Association.

The researchers said targeting three of the risk factors would have the most impact on dementia prevention. One of them, reducing hearing loss between 45 and 65, had not been quantified before.

The researchers estimated reducing hearing loss in mid-life could cut the number of dementia cases by 9 percent. They don't yet know why hearing loss is a risk factor for dementia, but said it could lead to social isolation and depression, which are known to contribute to cognitive decline. They said more research is needed to see if hearing aids would reduce this risk.

Schooling beyond the age 15 would reduce the total number of dementia cases by 8 percent, the report estimated. The researchers said low education "is thought to result in vulnerability to cognitive decline because it results in less cognitive reserve," which Harvard Medical School describes as "your brain's ability to improvise and find alternate ways of getting a job done" and says is developed by a lifetime of education and curiosity.

The researchers estimated that stopping smoking later in life could reduce the number of dementia cases by 5 percent because quitting reduces neurotoxins and improves heart health, which then improves brain health.

Livingston told HealthDay that dementia is usually diagnosed later in life, but brain changes related to the disease develop years before the symptoms appear: "We believe that a broader approach to prevention of dementia which reflects these changing risk factors will benefit our aging societies and help to prevent the rising number of dementia cases globally."

Artificial sweeteners linked to long-term weight gain, higher body-mass index and risk of heart disease, but we don't know why
Artificial sweeteners are "dodgy" when it comes to weight management, and people who use them regularly have higher risks of developing cardiovascular disease and diabetes, and bigger body-mass indexes, a height-weight ratio that indicates obesity.

So say a group of international researchers who reviewed more than 30 studies about the long-term health effects of sugar substitutes, Cleve R. Wootson Jr. reports for The Washington Post. Their research, published in The Canadian Medical Association Journal, covered more than 406,000 people who said they used artificial sweeteners.

Researcher Meghan Azad of the University of Manitoba said that while the studies show a link between artificial sweeteners and body-mass index, “We need more evidence from better-quality studies to know for sure the cause and effect, but there does seem to be at least a question about the daily consumption of these drinks."

The U.S. market for sodas decreased by 0.6 percent between 2011 and 2016, Wootston notes, but "close to half of adults and a quarter of children consume artificial sweeteners every day, according to the Journal of the Academy of Nutrition and Dietetics."

The American Diabetes Association and the American Heart Association approved the use of artificial sweeteners in 2014, but Wootson says people have become increasingly suspicious of aspartame, sucralose and steviocide, (brand names: Equal, Splenda and Stevia, respectively) because studies have linked them to increased belly fat, and "bogus but widespread rumors that they led to things much worse."

The ADA's chief scientific medical and mission officer, William Cefalu, reviewed the study at the Post's request and also concluded that more studies are needed. "He said artificial sweeteners are still a good tool for diabetics trying to reduce carbohydrates and tightly manage their blood-glucose levels. But he stressed moderation, and agreed that more studies about the long-term effects of artificial sweeteners were needed — particularly on people with diabetes," Wootson writes.

Azad said the study found “nonnutritive sweeteners significantly associated with modest long-term increases” in body weight, BMI and waist circumference, which has been linked to a greater risk of heart disease and diabetes.

But she stressed that they still don't know why these associations exists, and noted that most of the studies focused on people who were working to lose weight or had other medical conditions.

Azad offered several possibilities for the link between artificial sweeteners and increased BMI, ranging from the sweeteners causing changes in gut bacteria to the possibility that people who are gaining weight for other reasons may seek out more artificially sweetened foods.

Meanwhile, she advises "consumers to not automatically assume artificially sweetened foods are the healthier alternative," Wootson writes.

Friday, July 21, 2017

Introduction to adult food can be a big turning point in a child's nutritional health; program in 22 counties helps poor get local food

By Melissa Patrick
Kentucky Health News

Taste preferences are established early, and that's why those early bites of ice cream matter.
A program that helps low-income families who use food-assistance programs to get locally produced food gets additional funding.
A group in Louisville is working on opening a community-owned grocery store.

These were just some of the topics discussed during the July 12 "Food in Kentucky" webinar, sponsored by the Foundation for a Healthy Kentucky.

Ana Chang, founder of Concept Hatchery, a California consultancy, opened the webinar with findings from her company's research with the 1,000 Days project, which looks at the nutritional health of mothers and their children during the 1,000 days from pregnancy to a child's second birthday.

Chang said her research involved 19 mothers from Kentucky, California and Mississippi, with varying levels of income levels. The study looked at what the children ate and how the mothers decided what to feed them, through food journals and in-person evaluations during meal and snacks.

All of the children started out on equal footing because they were all fed either formula or breast milk, Chang said, but the nutritional value of their food changed quickly when they started eating adult food.

"The first taste of food that babies get are really often what the family eats; they are not specialized for babies. And so the taste preferences are established really early. Even as young as four months or younger, babies might be given a finger that's been dipped in soup that the family is having, or a lick of ice cream," she said. "So how well that family ate, that's how well that baby is going to eat as it starts growing up."

Chang noted that one of the Kentucky families in the study was part of a diabetes-prevention program that provided fresh produce to the whole family, even though only one family member had been diagnosed with the disease. "That is the kind of intervention that we need to start thinking about," she said, "because once food is brought into a family kitchen, it becomes available for everybody."

Chang noted some nutrition challenges for the low-income families in the study, including: lack of access to fresh fruits and vegetables, transportation barriers, lack of a safe place to store foods, and a lack of a cooking space. She said almost every family in the study struggled with food bounty and scarcity issues which were tied to the arrival of their paychecks and food stamps.

Martin Richards, executive director of the Community Farm Alliance, said his 32-year-old group focuses on agriculture and family farming policy because policy can affect the most people, but also supports non-legislative initiatives that reinforces the bills they are trying to pass.

Click on the image to view a larger version.
One of those projects is Kentucky Double Dollars, a program that allows low-income families who use food-assistance programs to double their purchasing power at participating farmers' markets and retail stores in 22 Kentucky counties.

The program allows those on food stamps (now called the Supplemental Nutrition Assistance Program) or the Women, Infants and Children program to double the value of their SNAP or WIC dollars to buy Kentucky-grown produce, meats, eggs and dairy products. The double dollars program is also available to seniors who are part of the Senior Farmers Market Nutrition Program for Kentucky-grown produce only.

"We saw the huge amount of money that comes into Kentucky from federal food nutrition programs and we saw this as a way to get that money to support local and regional food systems," Richards said, adding that the program recently received an additional $1.4 million from federal, state and private-sector funding to help sustain it. (The program was formerly called "Double Dollars," but recently changed its name to Kentucky Double Dollars after it merged with the Bluegrass Farm to Table and the "Bluegrass Double Dollar" programs in Lexington.)

This season, 27 Kentucky farmers’ markets, 12 Fresh Stop Markets in Lexington and Louisville, and Good Foods Co-op in Lexington and Lexington Market East End, are participating in Kentucky Double Dollars.

Other CFA initiatives include a program that gives children vouchers to use at participating farmers' markets; a program that allows health-care providers to prescribe fruits and vegetables as part of a treatment plan; a program that provides food to children in the summer; a walking program that links farmers' market vouchers to community exercise goals; a school-based program that encourages students to drink water; and healthy cooking classes.

The CFA also offers technical and financial support through a 50-50 cost-sharing arrangement to communities that want to create a farmers' market. "When a farmers' market has somebody dedicated to help making that market run, even if it is just part time and seasonal, it makes a huge difference to that market," Richards said.

In another part of the webinar, Cassia Herron of the Louisville Food Co-op said her group is working to open a community-owned grocery store in one or more of the neighborhoods in Louisville's urban core. She said this group is working to hire a project manager who will lead and launch a capital campaign for this project, which they hope will come to fruition within the next two years.

Thursday, July 20, 2017

In a region blessed with nature's hidden splendor, organized hiking could be a way to improve the health of Central Appalachia

Breathitt County Hiking Club walks the Copperas Creek Trail
in the Red River Gorge. (Outside photos by Josh Mauser)
An Eastern Kentucky man is working to improve the health of his county one person at a time through a monthly hiking club, Lyndsey Gilpin of Louisville reports for Outside.

Stephen Bowling, Breathitt County's 45-year-old library director, told Gilpin that he created the Breathitt County Hiking Club to get people in and around Jackson out into nature in hopes of improving their health and alleviating the sense of fatalism that is pervasive in the community. The trips usually attract around 20 people.

“A little bit here, a little bit there. We’ll get them moving,” Bowling told Gilpin.

Appalachia is "isolated geographically and culturally" and is a "prime example of the rural-urban wellness divide," Gilpin writes, noting that one in four people in Eastern Kentucky live below the poverty line; that nearly half of the 14,000 people who live in Breathitt County are obese; that about a third of them smoke; and that a third of them are physically inactive. The unemployment rate is almost 12 percent.

Those factors give Breathitt and surrounding counties some of the country's lowest health rankings, along with low life expectancy driven by unemployment, relatively low education levels, limited physical activity and poor access to health care and healthy foods, according to the annual Robert Wood Johnson Foundation County Health Rankings Report.

“It’s a depressed area economically, but also emotionally and physiologically,” Bowling told Gilpin. “We’re told constantly that we’re the least healthy people, we are this, we are that, and people don’t feel empowered to change that. Some people aren’t willing, and some people aren’t able.”

So Bowling, who has hiked hundreds of miles on the Appalachian Trail and in the Southeast, decided to share his love of backpacking with others in his community through a hiking club, which meets once a month on a Sunday, always after church.

He told Gilpin that he the club isn't a "one-and-done solution to all the public health woes facing Breathitt County," but added, "If we solve one problem at a time, or help someone get in shape one person at a time, we’ve completed our goal.”

Stephen Bowling helped rookie hikers on the trail.
Gilpin met up with Bowling and his hiking club in early June when he and a group of 14 hikers, most with no hiking experience, headed off to Copperas Creek Trail in the Red River Gorge, about 40 minutes away.

“Wow, this is just amazing,” said 47-year-old Julie Stamper, one of the hikers, as she put her cigarette out and stuffed the butt into her backpack. “I’ve never been to a place like this before.”

Bowling and others believe more access to public lands and increased opportunities for physical activity can help address some of these health problems and research supports this idea, Gilpin reports.

"Ironically, rural communities tend to be cut off from public land, leaving them with the fewest choices for outdoor activity and exercise," Gilpin writes, reporting that most Southeastern states have less than 5 percent federal public land and in Kentucky it's even less at 4 percent.

For example, Gilpin writes, "Only 17 percent of Breathitt county residents live within a half-mile of a park or within three miles of an accessible recreational facility; meanwhile, 98 percent of New York county residents and 100 percent of San Francisco county residents have such access to a park within a half-mile or a recreational facility within just one mile."

The Red River Gorge is part of the Daniel Boone National Forest, which is vast but is at least a half-hour from Jackson. With few places to exercise, “Many people rely on the local high school to keep its running track unlocked and open to the public,” Mark Holmes, director of the North Carolina Rural Health Research and Policy Analysis Center, told Gilpin.

Gilpin notes that rural Southern regions are looking at North Carolina and Colorado for ways to make public lands profitable and accessible, and that the state recently created the Kentucky Mountain Regional Recreation Authority, "a group run by community members from around the state that will develop, maintain, monitor, and promote local trails."

State Representative Chris Fugate, who sponsored the bill, told Gilpin that his goal is to connect 17 counties through a trail system. “Some of the most beautiful places are hidden away,” Fugate said. “We haven’t done a good enough job of promoting and taking care of ourselves here.”

Gilpin writes, "How these types of local programs fare and how public lands prove to help the situation could inform the conversations of policymakers moving forward."

Wednesday, July 19, 2017

Owensboro Health is sixth hospital to join UK's Markey Cancer Center Research Network; will bring clinical trials to patients

Patients at Owensboro Health will have easier access to clinical research studies through the hospital's new partnership with the University of Kentucky Markey Cancer Center.

Markey Cancer Center is a National Cancer Institute-designated cancer center, which will open the hospital to up NCI-led trials in addition to other trials in Markey's research network. "Cancer care is constantly improving, due in part to the groundbreaking work being done in clinical research," Dr. Tim Mullett, medical director of the research network, said in a news release.

"Our state has some of the worst cancer incidence and survival rates in the entire country, and we at Markey have an obligation to address this devastating disease. By increasing access to many of our current clinical trials through the Markey Cancer Center Research Network, we have an opportunity to make real progress in improving cancer statistics in Kentucky."

Owensboro Health is now one of six research sites in the network, and the first in Western Kentucky. The hospital's Mitchell Memorial Cancer Center sees more than 1,000 cancer patients annually and serves nearly 400,000 people from 14 counties in Western Kentucky and Southern Indiana.

The research will include "epidemiology, prevention and early detection of cancer," and will target cancers with the highest incidence and mortality rates in Kentucky, including lung, colorectal and cervical cancers, the hospital said.

"Clinical trials represent the latest, best treatment options for most patients, and being able to participate in major national and regional clinical trials right here in Owensboro means that patients are able to stay closer to their own support systems at home and under the direct care of their doctors here," Dr. Mark Evers, director of the UK Markey Cancer Center, said in the release.

The network also includes Hardin Memorial Hospital, Elizabethtown; King's Daughters Medical Center, Ashland; St. Claire Regional Medical Center, Morehead; Tri-State Regional Cancer Center, Ashland; and St. Mary's Regional Cancer Center, Huntington, W.Va.

Tuesday, July 18, 2017

Opponents dominate public hearing on Kentucky's revised proposal for changes in state Medicaid program

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Only three of the 17 Kentuckians who spoke at the final public hearing on changes to the state's Medicaid proposal supported it. The advocates said the work requirements "will make their lives better" and cited personal responsibility as reasons for their support.

Opponents, however, said the changes create a barrier to care for some of the state's most vulnerable citizens, and called the waiver "cruel, irresponsible and wasteful" "reprehensible and immoral" and likened the recent changes to "putting lipstick on a pig."

The changes have stronger work and volunteer requirements and a six-month "lock-out" for those who fail to report changes in their work and employment status.

The original proposal for a waiver to make changes to Medicaid was submitted to the Centers for Medicare and Medicaid Services about 10 months ago. The proposal targets "able-bodied adults" without dependents who qualify for Medicaid through the expansion of the program to those who earn up to 138 percent of the federal poverty level, under the Patient Protection and Affordable Care Act.

If federal officials approve the revised waiver, as expected, the state estimates that 95,000 fewer Kentuckians will be on Medicaid in five years than if the proposal is not accepted. Kentucky has 1.4 million Kentuckians on Medicaid, 470,000 of them through the expansion.

More than half of Kentuckians who have coverage because of the expansion work at low-income jobs that typically don't provide health insurance.

Andrea Welker, a lawyer with the Child Advocacy Today legal clinic in Lexington, said her mother falls into this category and that she was there to speak on her behalf about her concerns that she might lose her health insurance, which has been a "blessing," because her work hours vary so much from week to week.

“So when she goes to work, she gets there that day wondering if they are going to send her home four hours early and if she's going to be able to work her full shift. And at the end of the day, at the end of the week, is she going to be able to make her bills," said Welker.

Harriett Seiler of Louisville, a longtime advocate of single-payer health care, said the changes to the waiver were like "putting lipstick on a pig," saying they did nothing to improve it. She added that she "objects strongly" to the waiver's "patriarchal concept" of teaching people how to be "good employees, good purchasers of private insurance."

Rev. Rachel Small-Stokes, an associate pastor at Union Church in Berea, talked about the transportation challenges people in her community have to work, also noting that often they get to a workplace and are told they aren't needed. She added that "out of the goodness of their heart," the transportation burdens will likely fall to community members to get these people to and from their newly required work and volunteer requirements.

“And I actually wonder if maybe the underlying goal of this is for people not to get health care," she said. "And if that is the case, then it is absolutely immoral and so I urge you please re-look at this."

Beverly May, a family nurse practitioner from Floyd County, described the plan as "cruel, irresponsible and wasteful." She said the expansion has doubled the percentage of Kentuckians with a medical home and the uptake of preventive services, like breast and colorectal cancer screenings. She said the proposed changes in the waiver simply provide "unnecessary barriers" to care.

Some favor the changes

Amy Luttreel, chief executive officer of Goodwill Industries of Kentucky and also a spokeswoman for the Kentucky Workforce Innovation Board, said both organizations endorse the bill, primarily because of the work requirements, which “will make their lives better.”

“We also see this waiver as something that brings new tools to help people who are not in the workforce, but who could be in the workforce -- to help them to achieve more stability in their lives and to also gain the skills that would allow them to be competitive in today's labor market,” Luttreel said.

Johnny Pittman of Louisville spoke about personal responsibility, saying he had been on disability and Medicaid at times due to multiple sclerosis, he is now able to work and that it was his responsibility to do so. He works at Oxmoor Auto Group in Louisville.

“Disability and Medicaid worked great for me,” he said. “It was a program and a vehicle to get me to a point where I needed to be.”

One speaker who favored the waiver said administrative difficulties at the Department for Community Based Services need to be fixed before the work and volunteer requirements are put in place.

Dylan Gorski, a law clerk at the Child Advocacy Today legal clinic, said he was “totally in favor of the waiver,” but implored the Bevin administration to make sure DCBS was ready to handle the additional administrative responsibilities that would come with the waiver's proposed community engagement requirements.

He cited several examples where his clients had lost coverage because of administrative and system errors and said the waiver needs an “agency error exception” to keep Kentuckians from being locked out of their health insurance because of any agency error.

The modifications would require able-bodied adults who are not medically frail or a caretaker to work or volunteer 20 hours a week, or 80 hours a month, instead of the original proposals plan to gradually increase the number of hours required, until the participant reached the maximum of 20.

The updated proposal also includes a provision to "lock out" for six months any participant who fails to report a change in circumstances, such as income, employment and community status, which are used to determine eligibility.

Kent Gilbert, pastor and president of the executive board of the Kentucky Council of Churches, called the changes “reprehensible and immoral.”

Health Secretary Vickie Yates Brown Glisson, asked after the meeting to reply, said " I understand their position. . . . But I likewise feel very strongly that we are doing the right thing for Kentucky. So I'm very comfortable with that."

About 45 opponents showed up to speak, filling up an overflow room next to the legislature's Interim Joint Committee on Health and Welfare meeting that started at 10 a.m. and ended at 12:15 p.m.. The hearing was scheduled to follow the committee meeting, which ended up having 10 weighty items and several speakers. Many who came to speak at the hearing left before it even began.

“I think it was planned to put so many things on the agenda,” Rep. Mary Lou Marzian, D-Louisville, told Ronnie Ellis of CNHI News Service. “They don’t want people to know how callous they are.”

Committee Chairman Addia Wuchner, R-Burlington, told Marzian during the meeting that everyone would have the opportunity to speak after the meeting and noted that all of the agenda items were important issues that needed to be considered as they prepared for the 2018 legislative session.

Glisson said the remarks would be transcribed and attached to the waiver request sent to Washington. She also noted that the state was "still in a process of negotiation."

The state and CMS will continue to take written public comments through Aug. 2 at 11:59 p.m. 

Monday, July 17, 2017

After fellow Republicans kill his bill, McConnell adopts an idea he had dismissed: repeal Obamacare now, replace it later

Sen. Mitch McConnell (Getty Images)
By Al Cross
Kentucky Health News

With his health-insurance bill killed by fellow Republicans late Monday, Senate Majority Leader Mitch McConnell quickly adopted a version of idea he had dismissed: repealing the Patient Protection and Affordable Care Act, but with a two-year delay.

But that strategy quickly fell apart, as Republican senators from West Virginia, Maine and Alaska said they couldn't support it. That could make operative the warning McConnell gave Republicans last month, that if they couldn't pass a comprehensive bill on their own, they would have to join with Democrats to stabilize the market for private health insurance.

But John Bresnahan and Burgess Everett of Politico reported that McConnell "is wary of following Sen. Lamar Alexander (R-Tenn.) and other Republicans into bipartisan negotiations to save the insurance markets, according to GOP sources."

After Republican Sens. Jerry Moran of Kansas and Mike Lee of Utah said in a joint announcement Monday night that they couldn't support McConnell's revised bill, he said he would use the House passed May 4 as a vehicle for a repeal-now, replace-later strategy like that advocated by his Kentucky seatmate, Republican Rand Paul. President Trump had also suggested that strategy, and did it again Monday night.

McConnell had said the strategy wouldn't work, but around 10:45 p.m. Monday, he issued this statement: “Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful. In the coming days, the Senate will vote to take up the House bill with the first amendment in order being what a majority of the Senate has already supported in 2015 and that was vetoed by then-President Obama: a repeal of Obamacare with a two-year delay to provide for a stable transition period to a patient-centered health care system that gives Americans access to quality, affordable care.” He declined to be more specific about “the coming days.”

Sens. Jerry Moran, Mike Lee (N.Y. Times)
Around 9 p.m., Lee and Moran had joined Paul and moderate Republican Susan Collins of Maine in publicly opposing McConnell's revised bill. That left the majority leader two votes short of the 50 he needed from Republicans to advance the bill.

Asked June 30 about the idea of repealing now and replacing later, McConnell said he would "stick to" his strategy of passing a comprehensive repeal bill only with Republican votes.

McConnell said in early June that he wasn't working with any of the 48 Democrats because "They're not interested in doing anything we're interested in doing" on health care, but in late June he warned Republicans that if they couldn't pass a comprehensive overhaul on their own, they would have to join with Democrats to stabilize the market for private health insurance, including taxpayer-subsidized plans.

"My suspicion is in any negotiation with Democrats will include none of the reforms that we would like to make on the market side and the Medicaid side," McConnell said then.

Before McConnell's late-night announcement, Senate Democratic Leader Chuck Schumer of New York called for a bipartisan effort. “This second failure of Trumpcare is proof positive that the core of this bill is unworkable,” Schumer said. “Rather than repeating the same failed, partisan process yet again, Republicans should start from scratch and work with Democrats on a bill that lowers premiums, provides long-term stability to the markets and improves our health-care system.”

McConnell had promised a vote on his bill this week, but had to back off when Sen. John McCain of Arizona was sidelined by surgery. Paul said Sunday that the delay would give conservatives time to realize that the bill wasn't what they want.

McConnell had hoped to get Lee's vote by allowing insurance companies to sell the sort of low-cost, low-coverage plans that the 2010 law prohibited. (Insurance companies said the language would split the insurance market between the health and not so healthy, driving up costs for the latter.)

Sweeteners that McConnell added to the bill to get moderates, such as more money to treat opioid addiction and a one-year delay in the phase-out of Medicaid expansion, forced him to keep Obamacare's taxes in the bill, and Lee objected to that.

Also, The Associated Press reports, Lee said the bill didn't "go far enough in lowering premiums for middle class families" or "create enough free space from the most costly Obamacare regulations." Moran said the bill "fails to repeal the Affordable Care Act or address health care's rising costs."

"Moran faced pressure at home about how the bill would affect Kansas, including its rural hospitals," The New York Times noted, "The Kansas Hospital Association said last week that the latest version “comes up short, particularly for our most vulnerable patients.”

The Kentucky Hospital Association likewise opposed McConnell's plan to phase out federal funding for expansion of Medicaid, which has boosted many Kentucky hospitals. It said that if the expansion was phased out, Congress should restore the 2010 law's cuts in special reimbursements to rural hospitals for care of Medicare patients.

"The collapse of the Senate Republican health bill — and the failing struggle to find yet another alternative —highlighted a harsh reality for Senate Republicans: While Republican senators freely assailed the health law while Mr. Obama occupied the White House, they have so far not been able to come up with a workable plan to unwind it that would keep both moderate Republicans and conservatives on board," writes the Times' Thomas Kaplan.