Thursday, June 22, 2017

McConnell would phase out Medicaid expansion through 2024, cut old Medicaid after that; bill short of votes; Paul not on board

By Melissa Patrick and Al Cross
Kentucky Health News

Senate Republicans' bill to repeal and replace the Patient Protection and Affordable Care Act delivered few surprises but drew deadly opposition, putting Kentucky's senators on opposite sides.

Journalists mobbed McConnell. (Photo: Doug Mills, New York Times)
“I’m pleased that we were able to arrive at a draft that incorporates input from so many different members, who represent so many different constituents, who are facing so many different challenges," Majority Leader Mitch McConnell, who directed drafting of the bill by Republicans in secret, said in a floor speech.

Republicans hold 52 of the 100 Senate seats, so McConnell can afford to lose only two votes in his own party, and four Republicans -- including Rand Paul of Kentucky -- announced that they are opposed to the current version.

“Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation," the senators said in a statement. "There are provisions in this draft that represent an improvement to our current health-care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.”

Senators joining Paul were Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah. There was some doubt about the strength of the opposition from Cruz and Johnson. President Trump said the bill "is going to be negotiated."

Sen. Rand Paul
Paul told Kelsey Snell of The Washington Post, "The bill looks like we are going to keep all of the Obamacare subsidies — in fact, we may well exceed the Obamacare subsidies. That’s a problem. The bill establishes new money — about $130 billion — for what they call a 'stabilization fund.' That money is going to go to insurance companies that make a $15 billion profit. I find it unconscionable that we’re going to give money to insurance companies that make a $15 billion profit. Those two things don’t look like repeal to me."

If the bill passes the Senate and House and is signed by Trump, two of the biggest impacts in Kentucky would be a phasing out of the state's 2014 Medicaid expansion by 2024, followed by cuts to traditional Medicaid in 2025.

Kentucky is one of 31 states that expanded Medicaid to anyone with household income up to 138 percent of the federal poverty line, $12,060 for an individual and about $33,000 for a family of four. Medicaid covers 1.4 million Kentuckians, 470,000 of them through the expansion.

Under a repeal-and-replace bill passed by the House, Medicaid expansion would end in 2020. Under the Senate bill, it would remain the same until 2021, but would be phased out over the following three years.

Then, federal support for traditional Medicaid would decrease, because it would have spending limits based on population rather than reimbursing a state a percentage of whatever it spends, based on a formula that gives poorer states more money. In Kentucky, the federal government pays about 70 percent of costs for traditional Medicaid recipients and 90 to 95 percent for expansion members.

"The cap imposed by the House would grow more slowly than Medicaid spending has, but the Senate’s cap would grow even more slowly than the House’s," Julie Rovner reports for Kaiser Health News. "That would leave states with few options, other than raising taxes, cutting eligibility, or cutting benefits in order to maintain their programs."

Kentuckians who buy private, subsidized health insurance on the federal exchange would also be affected by the Senate bill. 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.

The 142-page bill would lower the qualifying level for people to get subsidies, starting in 2020, to 350 percent of the poverty line from 400 percent (about $94,000 for a family of four).

The bill also eliminates billions of dollars in taxes, mostly for the wealthy and the health-care industry, that are being used to pay the subsidies and the cost of the Medicaid expansion. The proposed tax cuts drew fire from Democrats.

Rep. John Yarmuth
“As the Senate proved again today, Trumpcare’s core mission is not to provide health care to Americans, but to give millionaires tax breaks and fundamentally end Medicaid as we know it," Democratic U.S. Rep. John Yarmuth of Louisville, said in a statement. "The results would be devastating for families: millions of Americans would lose coverage, key health-care protections would be taken away, and crucial services for seniors needing long-term care, children with disabilities, people struggling with addiction, and low-income families would be eliminated."

Jason Bailey, executive director of the Kentucky Center for Economic Policy, said in a statement: "No state has more to lose from this bill than Kentucky because no state has achieved more health and coverage gains in the last few years thanks to the Affordable Care Act. The bill would reduce Kentuckians’ health, harm the state’s most vulnerable and set us further back on fighting Kentucky’s opioid crisis. It will result in less coverage at higher cost, especially for poorer, older and sicker people. It will also lead to substantial job loss at hospitals and doctors’ offices and weaken Kentucky’s rural economies in particular."

In his floor speech, McConnell cited increases in premiums for Obamacare policies and said the 2010 law isn't working. "More Americans are going to get hurt unless we do something," he said. "American families deserve better than its failing status quo — they deserve better care."

The Senate bill would keep the Obamacare provision allowing children to stay on their parents' insurance policies until they turn 26. It would also keep the requirement for insurers to cover those with pre-existing conditions and charge them the same regardless of health history. However, it would allow states to waive some consumer protections such as the 10 essential health benefits, like maternity care and mental health treatment, that Obamacare requires in all insurance plans.

"This would allow insurers to offer less comprehensive policies, so those with pre-existing conditions may not have all of their treatments covered," CNN reports. It could "completely reshape the private insurance market," Danny Vinik of Politico reports. The bill also allows states to apply for federal waivers to eliminate the Obamacare mandate that barred insurers from setting a lifetime limit on an individual's benefits, The New York Times reports.

The bill would repeal the individual and employee mandates for buying health insurance. It would allow insurers to charge older people five times as much as younger ones; the current limit is three times. It would de-fund Planned Parenthood for one year.

Grant County coalition wins passage of 'complete street' policies to improve the health of its citizens

Grant County High School student Brookynn Scudder urged
the Crittenden City Council to adopt a complete-streets policy.
A Grant County coalition has embraced a policy to make future streets in the county safer for all potential users, and one city's effort to enact such policies involved the county's youth.

The Fitness for Life Around Grant County coalition partnered with the Foundation for a Healthy Kentucky to adopt "complete streets" policies that ensures future projects are planned and designed around not only automobiles, but also pedestrians, bikers, motorists and transit riders of all ages and abilities.

Grant County is the first in Kentucky to enact a county-wide complete street policy, and such policies have also been enacted in its four towns: Corinth, Crittenden, Dry Ridge and the county seat of Williamstown.

Ben Chandler, president and CEO of the foundation, called complete-street rules "pro-health policies" that make it easier for community members to make healthier choices.

"People are more likely to forgo their cars when they have convenient, well-lit and well-maintained sidewalks, walking paths and bicycling lanes," he said in a news release. "And one of the best arguments for complete streets laws is they don't require a large up-front appropriation, because they guide future planning efforts and maintenance priorities."

Grant County's coalition is part of the foundation's "Investing in Kentucky's Future" initiative, a five-year, $3 million program, that provided matching grants and training to seven multi-sector community health coalitions across the state to address children's health issues. FFLAG selected childhood obesity as one of its issues to address under the foundation grant.

"The Foundation grant requirements, training and other support for changing systems and policy really spurred us to look at how we could improve walkability in our communities," Elizabeth Steffer, a health educator with the Northern Kentucky Health Department, which is a member of the FFLAG coalition, said in the release. "These new policies will lead to behavior changes that will long outlive the grant."
Example of the Grant County High School students' walkability assessment
presented to the Crittenden City Council to promote complete-street policies
Grant County youth played an active role in getting the policy passed in Crittenden, the most recent city in Grant County to pass the policy. Under Steffer's leadership, youth from Grant County High School worked with the coalition and the Step It Up Kentucky! campaign to get the policy passed.

The effort involved eight students who did a walkability assessment of Crittenden and then compiled their observations and photographs into a presentation to the Crittenden City Council in May, asking members to adopt the complete street policy, which they did on June 6.

"The students told council members that they had the power to make Crittenden healthier, and their presentation made all the difference in getting the ordinance passed," Steffer said.

Student Blake White said in the release that his work on the project was meaningful because it would help ensure the safety of his younger brother, who loves to ride his bike around the community.

The 2016 Kentucky Health Issues Poll found that one in four Kentucky adults rated their neighborhoods only a fair or poor as a place to walk, jog or bike. Two in 10 said their neighborhood was either somewhat unsafe or not at all safe for exercise.

"In addition to encouraging physical activity, enhancing community walkability attracts business investment and increases small business revenue," Chandler said.

Taylor Mill and Independence in Northern Kentucky have also passed complete-street policies.

Attorney General Beshear joins multi-state effort to investigate role of drug manufacturers in opioid crisis

By Melissa Patrick
Kentucky Health News

Attorney General Andy Beshear announced June 21 that he is working with attorneys general from across the nation to investigate whether drug manufacturers contributed to the opioid epidemic by illegally marketing and selling opioids, according to a news release.

Through May 2016, 1,248 Kentuckians had died from a drug overdose, according to the Kentucky Office of Drug Control Policy. This five-month death toll was almost as many as all of the overdose deaths in Kentucky in 2015: 1,297.

"We know that we had 3.5 billion doses of opioids prescribed in Kentucky last year and that is enough for 79 pills per man, woman and child. That's huge," Rep. Kim Moser, R-Taylor Mill, told Kentucky Health News in March.

Moser was explaining House Bill 333, which imposed harsher drug penalties and limited painkiller prescriptions to a three-day supply if prescribed for acute pain. Moser, sponsor of the bill, is the director of the Northern Kentucky Office of Drug Control Policy.

“The single greatest threat to Kentucky is our drug epidemic,” Beshear said in a news release. “The crisis is killing our family and friends – it is the main source of crime in our communities and it is preventing job and economic growth. This is the crisis of our times, and finding a solution requires everyone working together.”

The announcement was made following a lawsuit filed in Ohio earlier this year against Purdue Pharma, Endo Health Solutions, Janssen Pharmaceuticals, Cephalon and Allergan. The suit accuses the drug manufacturers of "misrepresenting the risks of prescription opioids and helping to fuel an addiction epidemic," NPR reports in an interview with Ohio's attorney general.

Beshear's office previously settled a lawsuit, filed by predecessor Greg Stumbo, against Purdue Pharma over OxyContin. The $8 million settlement was given directly to 15 substance-abuse treatment centers throughout Kentucky.

From a different drug-company settlement, Beshear's office allocated $2 million to expand and enhance Rocket Docket programs that expedite drug cases and allow select defendants rapid access to substance abuse treatment.

Beshear has also joined a multi-state lawsuit alleging the maker of Suboxone, a drug used for treating opioid addiction, tried to monopolize the market.

Bevin declines to join bipartisan group of governors' call for continuation of formula used to fund state Medicaid programs

By Al Cross and Melissa Patrick
Kentucky Health News

A bipartisan group of governors, including Kentucky Gov. Matt Bevin, is asking Congress not to shift health-care costs to the states, a real prospect as the Senate prepares to vote on a bill to repeal and replace the Patient Protection and Affordable Care Act.

However, Bevin declined to join the group's request to maintain federal funding rates for Medicaid, the program that covers 1.4 million Kentuckians and is in for big changes if Senate Republicans' health bill becomes law.

Bevin and Kentucky are part of the Governors' Bipartisan Health Reform Learning Network, organized by the National Governors Association Center for Best Practices. It has six Republican and seven Democratic governors from California, Delaware, Kentucky, Minnesota, Montana, Pennsylvania, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington and Wyoming.

The governors summarized their priorities Wednesday, as details of the Senate bill were leaking out. It would end the Medicaid expansion later than a bill passed by the House, but would use a less generous formula for funding state Medicaid programs, beginning in 2025.

statement of "shared priorities" from the 13 governors in the network says, "It is critical that Congress . . . not shift costs to states. Significant cuts to Medicaid will impact coverage for millions of low-income individuals and could impede state efforts to address the underlying factors driving health care costs."

It also said, "For the majority of the network states that expanded Medicaid, maintaining coverage for those populations at the federal matching rate under current law is of critical importance. (With the exception of Kentucky which does not agree with this statement)."

Bevin's predecessor, Democrat Steve Beshear, expanded Medicaid to people in households with annual incomes up to 138 percent of the federal poverty level. The federal government paid the full cost of the expansion until this year. It is now paying 95 percent, which will drop in annual steps to the current law's floor of 90 percent in 2020.

For traditional Medicaid patients, the federal government pays about 70 percent of the costs, based on a formula that gives poorer states higher reimbursement rates.

The governor's office didn't immediately respond to a request for comment on why Bevin declined to support this part of the statement. During his 2015 campaign, Bevin initially said he would abolish the expansion, and even after dropping that idea, said federal money shouldn't be accepted just because it is available, because it is taxpayer money.

Under the bill to be revealed Thursday, Medicaid funding would use "an even slower growth index than the one used in the House bill," reports Paige Winfield Cunningham of The Washington Post. "That move could prompt states to reduce the size of their Medicaid programs."

Wednesday, June 21, 2017

Senate GOP health bill would dramatically roll back Medicaid

Kentucky Health News

The health bill that Senate Republicans will unveil Thursday "would reshape a big piece of the U.S. health-care system by dramatically rolling back Medicaid while providing a softer landing to Americans who stand to lose coverage gained under the Affordable Care Act," Paige Winfield Cunningham reports for The Washington Post.

As Kentucky Health News indicated Tuesday, the bill would "cut off Medicaid expansion more gradually than the House bill, but would enact deeper long-term cuts to the health-care program for low-income Americans," Cunningham reports. It also would keep Obamacare's income-based subsidies for private insurance, but scale them back.

"Subsidies are currently available to Americans earning up to 400 percent of the federal poverty level," Cunningham writes. "Starting in 2020, that threshold would be lowered to 350 percent under the Senate bill -- but anyone below that line could get the subsidies if they’re not eligible for Medicaid."

The House bill would end the Medicaid expansion, which serves 470,000 Kentuckians, in 2020. The Senate bill is expected to phase out the expansion over a longer period, but it would cut scale back the overall Medicaid program farther in the long run. "In 2025, the measure would tie federal spending on the program to an even slower growth index than the one used in the House bill," Cunningham writes. "That move could prompt states to reduce the size of their Medicaid programs."

That would be the biggest change in Medicaid since a heavily Democratic Congress created it in 1965, and would perhaps reflect the different attitude that Republicans have toward the program. "Republicans view Medicaid as a form of welfare, and pretty much everyone else views it as a government insurance program," Drew Altman of the Kaiser Family Foundation writes for Axios.

"Perceptions of Medicaid as welfare don't seem bothered much by facts, such as, for example, that two thirds of Medicaid spending goes for the low-income elderly and disabled who don't fit the Ronald Reagan era image of the welfare king or queen. But it's not the majority view in any case. A little less than a third of voters identify as Republicans today, and about half of them see Medicaid as welfare," Altman writes. "It's this group and their perceptions of the program, and elected officials who share their views, that seem to be driving debate about Medicaid today." About 1.3 million Kentuckians are on Medicaid.

Louisville senator hopes third time is charm for his bill to allow marijuana to be used to alleviate suffering of the terminally ill

Kentucky should join the states that have authorized marijuana for medical use, and allow it to be used to relieve suffering of the terminally ill, a Democratic legislator from Louisville told a House-Senate committee Wednesday.

McGarvey after the meeting (C-J photo by Deborah Yetter)
"It's 2017," Sen. Morgan McGarvey told the Health and Welfare Committee. "I think it's time we had a conversation about medical marijuana without snickering."

"Members of the committee took no action on legislation McGarvey is proposing for the 2018 legislative session, but no one spoke against the proposal and some committee members spoke in favor of the measure that went nowhere in the past two legislative sessions," Deborah Yetter reports for The Courier-Journal, quoting Sen. Tom Buford, R-Nicholasville: "This is an issue that's got to be dealt with some way."

McGarvey, who has "sponsored similar, unsuccessful measures in the last two sessions of the General Assembly," said public attitudes are moving toward medical marijuana "in some circumstances," Yetter reports. "And he said he doesn't believe support breaks down on partisan lines."

"Everyone has someone in their life who has suffered from cancer or a debilitating illness," McGarvey said. "What we're hearing from Democrats and Republicans is that we need to provide some relief."

McGarvey told the panel that 26 states already allow medical use of marijuana "and said he sees no reason Kentucky should wait any longer," Yetter reports. McGarvey said,"If you're last, you're last and Kentucky shouldn't be the last state to do this." He said it would not be a "back door" to recreational use of marijuana, as some states have done. "That's an argument made out of fear and not out of fact," he said. "It's not a back door to anything."

Yetter writes, "Several supporters of medical marijuana who attended the hearing said they don't think McGarvey's bill goes far enough, that it should allow broader medical use than just for those who are terminally ill. Among them was Dr. Don Stacy, a Louisville cancer doctor who said he has seen dramatic improvements in patients who acknowledge using marijuana 'behind closed doors' to ease pain and nausea from treatments including chemotherapy and radiation."

Tuesday, June 20, 2017

Ky. leads nation in opioid-addiction diagnoses for privately insured people, and in the rate of doctors prescribing medication for it

By Melissa Patrick
Kentucky Health News

Kentucky doctors diagnosed more cases of opioid addiction for privately insured people than in any other state in the nation last year, and the state had the nation's highest rate of medication-assisted treatment for addiction.

The findings are in a study, "America's Opioid Epidemic: Data on the Privately Insured Population," by Amino, a health-care transparency company that uses large sets of data to help people find low-cost care.

Looking only at privately insured patients "shows how pervasive this crisis has become" and that opioid use isn't just a problem for people on Medicaid, the report says.

Nationwide, the researchers found a six-fold increase in the number of patients diagnosed with opioid-use disorder between 2012 and 2016, rising from 241,000 to 1.4 million.

The American Society of Addiction Medicine estimated that in 2015, "about 2 million people in the U.S. had a substance use disorder with prescription painkillers and about 591,000 had a heroin-use disorder," Terry DeMio reports for The Cincinnati Enquirer.

The Amino report said its estimates were probably low, especially among the privately insured, because people are hesitant to get treated for addiction and physicians are hesitant to make the diagnosis because of the stigma attached to it, especially for those who get insurance through their employer.

Dr. Will Lopez, a senior medical director in Cigna's behavioral-health business, told DeMio that opioid-use disorders increased after doctors started prescribing more painkillers in the 1990s, when pain level started being considered a fifth vital sign.

"From the start of this problem, it went across all economical statuses," Lopez said.

Treatment with buprenorphine is highest in Kentucky

Addiction is often treated with substitute drugs, and Kentucky has the highest share of physicians prescribing medication-assisted treatment.

MAT medications include buprenorphine, methadone and naltrexone, which are prescribed along with counseling and behavioral therapies to treat opioid-use disorders and to prevent overdoses.

Click on table to view a larger version
Kentucky has nine of the top 10 counties in the nation for doctors using MAT to treat opioid-use disorder. They include Breathitt, Lee, Wolfe, Perry, Boyle, Floyd, Menifee, Bourbon and Rowan counties. All but Boyle and Bourbon counties are in Eastern Kentucky.

DeMio notes that the Northern Kentucky counties of Boone, Campbell and Kenton were not among the counties with high rates of physicians prescribing MATs, though these counties have been "hit hard by the heroin epidemic."

That could indicate illicit trade in MAT drugs in Eastern Kentucky, but there are other possible causes. Dr. Mina "Mike" Kalfas, a certified addiction expert at Christ Hospital's outpatient clinic in Fort Wright, told DeMio that this was because the region has too few MAT providers, leaving many who need the medication unable to get it here. This is a problem nationwide.

The federal Substance Abuse and Mental Health Services Administration reported in 2016 that "Half the people who could use treatment are not able to get it, in large part because they can't afford it or can't find providers." SAMHSA offers a burprenorphine physician-finder online.

The report adds that opioid-use disorders are linked to many serious health conditions. It found that patients with opioid addictions were nine times more likely to have hepatitis C and almost six times more likely to have chronic pain. They were also eight times more likely than people without addiction to have alcoholism, almost seven times as likely to have contemplated suicide, and were more than twice as likely to have anxiety and depression.

Kalfas told DeMio that many of these dual diagnoses make sense because of what heroin and synthetic opiates do to a user's brain. "The depression, suicidal thoughts, loss of joy, are consequences of chronic opioid use, because they experience a decrease in endorphins over time," Kalfas said. Endorphins are natural hormones that activate the body's opiate receptors.

Hepatitis C is linked to intravenous drug use because it is spread through the sharing of syringes. Kentucky has passed legislation for syringe-exchange programs that allow IV drug users to swap their dirty needles for clean ones to decrease the spread of diseases like hepatitis and HIV. As of June 16, the state had 24 operating syringe exchanges and nine that are approved, but not yet operational, according to the Cabinet for Health and Family Services website.

As for chronic pain, DeMio writes, "When states cracked down on the prescription of addictive painkillers, or opioids, used in an attempt to conquer chronic pain, drug cartels moved heroin into the market, and people who'd been cut off prescriptions along with others who'd been using the drugs sold on the streets started using heroin."

Senate health bill expected Thur., McConnell says; could stretch Medicaid expansion but then cut program more than House bill

By Al Cross and Melissa Patrick
Kentucky Health News

Senate Republicans plan to make their repeal-and-replace-Obamacare bill public on Thursday, Majority Leader Mitch McConnell of Kentucky told reporters Tuesday.

The bill is likely to continue the Medicaid expansion, which serves 470,000 Kentuckians, longer than the bill passed by the House, but could make deeper cuts to Medicaid in the long run.

McConnell talked and gestured as Republican Policy Committee
Chair John Barrasso of Wyoming, left, and Conference Chair
John Thune of South Dakota listened, while Republican Whip John
Cornyn of Texas looked away. (Associated Press photo : J. Scott Applewhite)
McConnell's announcement indicated that the bill is being analyzed by the Congressional Budget Office, which would clear it for debate, votes and perhaps passage on the Senate floor next week, meeting McConnell's goal of action before the July 4 week recess that begins Friday, June 30.

"I expect to have a discussion draft on Thursday, and we will go to the bill once we get a CBO score, probably next week," McConnell told reporters. Asked how long the Senate will have to review the bill, McConnell said "plenty of time."

On the floor Monday, Minority Leader Chuck Schumer of New York asked McConnell if the Senate would have more than 10 hours to debate the bill and McConnell wouldn't answer the question, saying only, "We'll have ample opportunity to read and amend the bill."

Schumer and other Democrats have been shut out of negotiations in the bill, which Republicans can pass with no Democratic votes because they are invoking budget rules that preclude a filibuster and bypass the 60-vote requirement to pass legislation.

McConnell said of Democrats, "They've made it clear they are not interested in helping" repeal Obamacare. Republicans plan no committee hearings on the bill, and note that Democrats passed Obamacare with only their own votes.

"No transparency would have been added by having hearings in which Democrats would have offered endless single-payer-system amendments," McConnell said. "That is not what this Senate was sent here to do."

McConnell's office is writing the bill, Republican Sen. Bob Corker of Tennessee told The Washington Times Monday: “The leader is really writing this bill. You can say the Finance Committee is, you could say the Budget Committee is, you could say the Health Committee is — but the leader’s office is writing the bill. And what they’re trying to do is sort of try to attempt hit the sweet spot between those differences that exist, which are natural when you have people from different states. I haven’t seen what that is yet, and to my knowledge no one has seen that yet.”

The Times reports, "Republican negotiators are still fine-tuning how make tax credits in their plan generous enough for certain cohorts, including the needy and older Americans who aren’t yet eligible for Medicare. Yet Sen. Rand Paul, Kentucky Republican, suggested his colleagues want to dole out more taxpayer assistance than the 2010 law they’re trying to scrap."

“One of the key things when it comes out, when we get a copy, is: Are there more subsidies in our bill than Obamacare?” Paul said. “That, to me, really is a non-starter.”

That could depend on what Paul calls a "subsidy." The word generally refers to tax credits and cost sharing for private insurance policies, but could also be applied to the heavy financial support that the 2010 health-reform law gives to states' expansion of the Medicaid program.

McConnell has suggested phasing out the Medicaid expansion through 2023, instead of ending it in 2020, but The Hill reports that the Senate bill could make deeper cuts to Medicaid in the long run: "According to lobbyists and aides, the proposal would start out the growth rate for a new cap on Medicaid spending at the same levels as the House bill, but then drop to a lower growth rate that would cut spending more."

That risks losing the votes of Republican senators such as Rob Portman of Ohio and Dean Heller of Nevada, and McConnell has only two votes to spare. If the vote is 50 to 50, Vice President Mike Pence can break the tie in favor of the Republicans.

"It may be too late to rally support . . . if reports coming out of a meeting of Republican senators are accurate, Rob Garver and Eric Pianin of The Fiscal Times report. "Sen.John Thune of South Dakota and Majority Whip John Cornyn [of Texas] exited a meeting of the Senate GOP caucus Tuesday afternoon and told reporters that there is currently no consensus among members on what the final version of the bill ought to look like." The writers add, "McConnell is the shrewdest politician on Capitol Hill and it would be a serious mistake to underestimate his ability to pull victory from the jaws of defeat."

McConnell "stopped short of guaranteeing that the bill would get the 50 Republican votes it would need to pass it when he brings it to the floor," notes Tierney Sneed of Talking Points Memo. McConnell replied, “We are going to make every effort to pass the bill that dramatically changes the current health-care law.”

The House Freedom Caucus, an ardently conservative group generally aligned with Paul, sent McConnell a letter warning him not to make bill too moderate. McConnell told reporters that the bill will be "a profound, positive improvement over the status quo."

Meanwhile, some lobbying groups expressed frustration at the inability to meet with McConnell. “It is deeply disturbing,” Erika Sward, assistant vice president of the American Lung Association, told the Los Angeles Times. “Patients groups like ours need to make sure that our patients’ needs for healthcare will be met. … We can’t do that if we can’t see what is being proposed.”

"Major physician groups, hospitals, consumer advocates and organizations representing millions of patients with cancer, diabetes, heart disease and other serious illnesses have been pleading with Republican leaders for months to open up the process and listen to their concerns," report Noam Levey and Lisa Mascaro of the Times. "This week, a group of more than 15 patients' groups . . . asked McConnell’s office to meet with them next week, proposing any time between Friday and June 22.

"A representative from McConnell’s office told them staff schedules were too busy, according to representatives of several of the organizations. McConnell spokesman Don Stewart said the majority leader’s schedule is full. 'Numerous meetings are already booked well in advance,' he said."

A group of 120 lobbies for consumer and health-care providers wrote McConnell a letter asking for the preservation of Medicaid, and the American Hospital Association said the Medicaid cuts being considered would have "serious negative consequences for communities across America."

Mike Rust, president and CEO of the Kentucky Hospital Association, told Kentucky Health News that the group has long taken two consistent positions: "Keep the expansion and if they repeal it, restore the cuts to Medicare" reimbursements, which were made when Medicaid was expanded.

Don Ritchie, historian emeritus of the Senate, told the Times that the Senate had not taken such a partisan, secretive approach to major legislation since said not since the years before World War I. That's when "Senate Democrats, at the urging of President Woodrow Wilson, drew up major tariff reforms while shutting out Republicans. But when Democratic leaders tried that again when they had large majorities during the Great Depression, rank-and-file senators revolted. It hasn’t happened since, he said."

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Post's chief fact-checker gives McConnell an upside-down Pinocchio for a flip-flop the senator won't acknowledge

"It has become a regular feature of the U.S. political system that the politicians in the minority accuse the politicians in power of cutting deals behind closed doors to advance controversial legislation — only to engage in similar tactics once they regain power," writes Glenn Kessler, who runs The Fact Checker column for The Washington Post.

And so it goes with Senate Majority Leader Mitch McConnell and Senate Republicans' health bill, says Kessler as he compares McConnell's recent remarks with those he made in 2009 and 2010 as Democrats were passing the Patient Protection and Affordable Care Act, better known as Obamacare. Kessler, a Cincinnati native, normally gives politicians one to four Pinocchios, depending on how far they stray from the truth; in this case, he gives the Kentuckian one upside-down Pinocchio "for statements that represent a clear but unacknowledged 'flip-flop' from a previously-held position." Here's a video version:

Monday, June 19, 2017

Study finds dog owners walk 22 more minutes per day, at a pace that improves health; Ky. seniors rank very low for physical activity

WebMD photo
By Melissa Patrick
Kentucky Health News

Dog owners walk on average 22 more minutes per day compared to people who don't own a dog, says a recent study.

"Not only did we see an increase in exercise, but also the exercise was at a moderate pace," study author Daniel Mills of the University of Lincoln, in the United Kingdom, told Allison Aubrey of NPR.

The study, published in the journal BMC Public Health, found at times the dog owners walked around 3 miles per hour, which the Centers for Disease Control and Prevention considers moderate intensity.

"Prior studies have shown that moderate-intensity walking is just as effective as running in lowering the risk of high blood pressure, high cholesterol, Type 2 diabetes and other conditions," Aubrey reports.

The study included men and women aged 65 and older who agreed to wear an activPAL monitor, which measure speed, distance and other factors 24 hours a day. Participants also self-recorded information about their own and their dog's demographics, daily responsibilities and sleep/wake times. The study started with 43 pairs of dog owners and non-dog owners.

And in addition to the additional 22 minutes of walking at a brisk pace, the study said participants added almost 3,000 additional steps per day and sat less often, though the total time spent sitting didn't vary much.

"The national physical-activity guidelines call for 150 minutes a week of moderate-intensity exercise, and that's what they got in this study," Robert Sallis, a family physician with Kaiser Permanente in California, told Aubrey about the study. Sallis was not involved in the research.

"If you look at studies on pet ownership, people who own pets seem to live longer than those who don't own them," Sallis said. He added that it's not just the increased activity that improves a persons health, but is also the companionship that pets provide which can lead to lower rates of depression and stress.

Kentucky's seniors are ranked third in the nation for physical inactivity, according to America's Health Rankings. They also ranked last in health outcomes, which measured things like self-reported health status, premature deaths and frequent mental distress.

Harvard Medical School also touts the many health benefits of having a pet, but cautions that they can be expensive to care for, require a lot of work, can pose sanitary risks and that they can sometimes pose a health hazard for older adults.

"If you have problems with gait and stability and your pet can get under your feet or jump up and knock you over, then falls and broken bones are a real danger," psychiatrist Dr. Greg Fricchione, director of the Harvard-affiliated Benson-Henry Institute for Mind-Body Medicine, said in the article.

For a fee, the medical school has published a special health report called "Get Healthy, Get a Dog," that offers advice on how to choose the best pet to suit your lifestyle, as well as the role of service dogs.

Sunday, June 18, 2017

Frankfort area has an outbreak of a new, stronger strain of dog flu; cats could also be affected; vets say pets shouldn't socialize

Hattie relaxes at East Frankfort Park Wednesday afternoon.
Her owner said she will get her canine flu vaccination soon.
(State Journal photo by Austin Horn)
Dog owners in Franklin County are being warned to keep their pets away from others' pets because a strain of canine flu has become widespread in and around Frankfort.

Dr. Denis King of the Frankfort Animal Clinic told Austin Horn of The State Journal he found the H3N2 virus capital among “some dogs that had been boarding here [that] started coughing and were running fevers.”

"With 20 to 30 other dogs boarding at the clinic exhibiting similar symptoms — which include reduced appetite, high fever, cough, runny nose and lethargy — King said that it was safe to assume that they also contracted the disease," Horn reports.

"H3N2 is relatively new in the United States, having originated in South Korea in 2006 but only finding its way to the US in 2015," Horn writes. "It is most often spread through dog shows or other events and places where dogs congregate en masse according to Dr. Cynda Crawford, a professor and leading infectious-disease researcher at the University of Florida."

Dogs with the virus "can be contagious for up to four weeks even if they are no longer showing symptoms," Horn reports. "Crawford noted that dog owners should be aware of crucial differences between H3N2 and the other strand of dog flu, H3N8, with which Americans are more familiar. The most pertinent, she noted, is that H3N2 puts dogs at a much higher risk for pneumonia, which could prove fatal. And she added that the virus has been known to affect cats as well as dogs. While Crawford advocated for a temporary pause in dog exposure to boarding areas to stem the virus’ advance, she emphasized that vaccination was the most important step a dog owner can take."

The outbreak has prompted King's clinic and other pet-care facilities in Franklin County "that deal with large numbers of dogs to make their operations more conservative," Horn reports. "Jeff Poe, co-owner of Pet Domain and Suites, said he required all animals staying at the pet hotel to be vaccinated against the new flu. At the Franklin County Humane Society, a similar approach was taken according to technician Kerry Lowary. The humane society provided all its dogs with the new vaccine."

Saturday, June 17, 2017

Study says health bill passed by the House would cost Kentucky 16,500 jobs in the next decade

By Melissa Patrick
Kentucky Health News

A study says that if Congress and President Trump were to enact into law the health bill passed by the House, the nation would lose nearly 1 million jobs, 16,500 of them in Kentucky, in the next decade.

The study is from the Milken Institute School of Public Health at the George Washington University in Washington, D.C., and The Commonwealth Fund, a New York-based research foundation.

Their analysis of the American Health Care Act predicts it would initially increase the number of jobs and improve the economy because of the tax cuts that go into effect immediately, but those gains would soon be lost. “Cuts in funding for Medicaid and health subsidies then begin to deepen, triggering sharp job losses and broad disruption of state economies in the following years,” Leighton Ku, director of the Center for Health Policy Research at GWU and lead author of the report, said in a news release. “The downturn would hit the health-care sector and states that expanded Medicaid the hardest.”
Click here to link to an interactive map that shows the predicted impact of the ACHA on jobs.
Kentucky is one of the 31 states that expanded Medicaid under Obamacare to those who earn up to 138 percent of the federal poverty line. Almost 470,000 Kentuckians gained health insurance through the expansion. Only 82,000 are enrolled in Obamacare plans subsidized by federal tax credits.

The study predicts Kentucky would initially see an increase of 8,500 jobs, but between 2018 and 2026, when the Medicaid spending cuts and reduced funding for cost-sharing subsidies kick in, the state would lose almost 17,000 jobs, with 10,500 of them in health care. The report adds that Kentucky is one of 17 states where the number of health-care jobs would fall immediately.

Likewise, the study forecasts that Kentucky's gross state product, the value of goods and service produced in the state, would initially grow by $800 million and see an increase in business output of $1.5 billion, but by 2026 the GSP would be $1.6 billion lower and business output $2.6 billion less.

"The primary cause of the loss of jobs and harm to state economies is the large reduction in funding for health care, particularly cuts in Medicaid funding and reduced funding for tax subsidies to help people purchase health insurance," says the release.

Senate Republicans are working on their version of a bill to repeal and replace Obamacare and many of the provisions in the House bill are expected to carry over into it. But because the Senate bill is being drafted behind closed doors it remains uncertain what they will be.

The study said it looked at the potential economic effects of the AHCA based on "changes in federal funding gained or lost to states, consumers and businesses." Its estimates are based on projections from the nonpartisan Congressional Budget Office, which said 23 million fewer people would have health insurance in 2026 under the AHCA. A Centers for Medicare and Medicaid Services actuary concluded that the number of uninsured in 2026 would be closer to 13 million -- far fewer than the CBO report.

The report recognizes that conservatives want to reduce federal spending to lower the deficit, but says this strategy decreases jobs at the state level.

“Federal health funds are used to purchase health care. Then, fiscal effects ripple out through the rest of the economy, creating employment and other economic growth," says the report. “Health funds directly pay hospitals, doctors’ offices, and other providers; this is the direct effect of federal funding. These facilities use revenue to pay their employees and buy goods and services, such as rent or equipment; this is the indirect effect of the initial spending." The report adds that health-care employees and businesses then use their incomes to purchase consumer goods.

The authors note that the analysis has many limitations, including: the uncertainty around whether the AHCA or an alternative plan will be enacted into law; the inability to account for other legislation that would affect economic growth or employment; the flexibilities that the AHCA grants to states that could underestimate or overestimate individual state findings; and President Trump's budget that calls for an additional $610 billion in Medicaid cuts beyond those called for in the AHCA.

Friday, June 16, 2017

Some Republican senators, including Rand Paul, don't like Mitch McConnell's strategy of drafting health bill in secret

Kentucky Health News

Senate Majority Leader Mitch McConnell continues to catch heat from Democrats, and dissatisfaction from some Republicans, about Senate Republicans' secret drafting of a repeal-and-replace-Obamacare bill that he wants passed by June 30.

At the congressional baseball game, McConnell and Schumer
gave their first joint interviews, as did House Speaker Paul Ryan
and House Minority Leader Nancy Pelosi. (AP photo by Alex Brandon)
Senate Democratic Leader Chuck Schumer of New York told the Kentuckian in a letter that they should convene a meeting of all 100 senators "on the topic of health care," which "affects every single American and one-sixth of our economy. We believe we all owe it to our constituents to pursue any bipartisan potential legislation because it profoundly impacts so many American lives."

Schumer told reporters, “They’re ashamed of the bill. If they liked the bill, they’d have brass bands marching down the middle of small-town America saying what a great bill it is. But they know it isn’t.”

McConnell spokesman David Popp "argued that the letter suggests Democrats are now open to the 'repeal' component of the 'repeal and replace' health care effort," CNN reports. "He alluded to Schumer's comments earlier this year in which he said Democrats will work with Republicans on repairing Obamacare as long as Republicans back off of the 'repeal' part of it."

Popp noted that Schumer's letter said Democrats would like to "discuss how to make health care more affordable and accessible." Popp said that was an admission that Obamacare is neither. "That admission is another positive step from a party that, until now, has been wedded to the unsustainable status quo and its consequences for families across the country," he told CNN, urging Democrats to "propose ideas."

Meanwhile, seven governors — four Democrats and three Republicans — wrote McConnell and Schumer, asking that senators in both parties be allowed to help draft the bill. McConnell has said he wouldn't involve Democrats in drafting because "They're not interested in doing anything that we're interested in doing," and hearings aren't needed because the issues are well known.

Republican grumbles

The lack of "a formal, open drafting session . . . has created an air of distrust and concern — on and off Capitol Hill, with Democrats but also with Republicans," report Thomas Kaplan and Robert Pear of The New York Times. "The secrecy surrounding the Senate measure to repeal and replace the Affordable Care Act is remarkable — at least for a health-care measure this consequential."

Sean Sullivan and Kelsey Snell of The Washington Post report, "Rank-and-file Republican senators are increasingly frustrated that McConnell and a small group of GOP aides are crafting a bill behind closed doors."

They quote Sen. Bob Corker, R-Tenn.: “I’ve said from day one, and I’ll say it again. The process is better if you do it in public, and that people get buy-in along the way and understand what’s going on. Obviously, that’s not the route that is being taken.”

The Times reports, "Mr. McConnell said there had been 'gazillions of hearings on this subject' over the years — a less-than-precise tabulation that offered little comfort to Democrats who want hearings held now, in this particular year, on the contents of this particular bill."

Corker is not the only Republican who wants to know more, and sooner. McConnell's Kentucky colleague, Rand Paul, asked reporters if they had a copy of the bill, and if so, whether he could have one. Paul is considered one of the Republicans least likely to support the bill, since he said the House version didn't go far enough. “My preference would be a more open process in committees, with hearings and people on both sides,” he told the Times.

Among Republican senators, "Few seem to have a clear, coherent picture of what will be in the legislation," the Times reports, quoting Ron Johnson of Wisconsin: “I come from a manufacturing background. I’ve solved a lot of problems. It starts with information. Seems like around here, the last step is getting information, which doesn’t seem to be necessarily the most effective process.”

Republican rationale

The Post reports, "Senate leaders argued that they are keeping a tight grip on emerging bill language a secret because they are writing several different policy options for each section of the bill. They worry that sharing any one piece out of context could give a distorted impression of what the final bill will include."

The Times says, "It is not unusual for lawmakers to draft major legislation in private, but they usually refine, debate and amend it in open committee sessions. The House bill to repeal the Affordable Care Act did not receive a hearing where outside experts could have testified, but lawmakers dissected its contents and were able to propose changes at three stages: in the Ways and Means, Energy and Commerce, and Budget Committees. Senate Republican leaders evidently think their back-room approach gives them the best chance to devise a health care bill that can squeak through the Senate, given their narrow majority and the policy differences in their conference."

Fifty-two senators are Republicans, allowing defection by only two to let a bill pass with the tie-breaking vote of Vice President Mike Pence. McConnell plans to bring the bill to a vote by June 30, the last day before a week-long recess, the Post reports. If it passes, a House-Senate conference committee would be named to work out the differences.

"The largest, most enduring clash within the Senate is over the future of Medicaid," the Post notes. "Republican senators are at odds over how much and how quickly to pare back federal spending on the program, which expanded under Obamacare and added millions of Americans to the rolls of the federally insured." It added 470,000 Kentuckians.

Does McConnell really want to pass a bill?

Jennifer Rubin, a conservative columnist for the Post, wonders whether McConnell really wants to pass a bill: "There are two possibilities here: First, McConnell has some magic formula for getting the votes of all but one senator (if Paul is indeed a “no” vote ) in a conference that includes far-right ideological twins Sens. Ted Cruz (R-Tex.) and Mike Lee (R-Utah) and moderates such as Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska), who among other things object to rolling back Medicaid or blocking Planned Parenthood funding. If such a formula exists, McConnell would have to think he can garner support in lightning speed, hold off uniform Democratic objections and ignore concerns from outside groups (doctors, hospitals, insurers). I suppose anything is possible, but such a process would be unique in Senate history.

"The other possibility is that McConnell knows this is impossible. He has set an entirely artificial deadline that cannot be met precisely because he knows health-care reform won’t happen. He wants to wipe the slate clean and move on to other issues such as tax reform and the budget — before those issues become untenable. He is experienced enough to know that this administration and the dysfunctional House are entirely capable of careening toward a government shutdown in the fall. Therefore, the sooner Congress can turn to these items, the better."

The Times notes, "While much of the Affordable Care Act was written in the open, some important provisions were hashed out in private, just before the Senate vote, by Senator Harry Reid, the Nevada Democrat who was then the majority leader. Republicans complained bitterly at the time, and Democrats threw those complaints back at them this week. 'This massive piece of legislation that seeks to restructure one-sixth of our economy is being written behind closed doors, without input from anyone, in an effort to jam it past not only the Senate but the American people,' Mr. McConnell said in December 2009, using words that could be spoken by any Democrat today."

Anderson Co. Middle School bans fictional teen suicide book from curriculum; school psychologists' group has concerns about book

Anderson County Middle School will no longer use a fictional book on teenage suicide for classroom instruction, citing a controversial Netflix series that is based on the book as a contributor to this decision, Ben Carlson reports for The Anderson News.

“The series played a factor in the decision to no longer use the book,” Supt. Sheila Mitchell told Carlson. “Also, the manner in which the book was beginning to be used for fall 2016 was not the original intent, so the principal informed the teacher to find other resources to support the concept.”

Principal Jenna Rose told Carlson that portions of the book, 13 Reasons Why, had been approved for use in a middle-school enrichment class during the 2016 spring semester to support a concept in standards. The book was not being used in any of the elementary or high schools.

The book "follows a fictional character named Hannah Baker who leaves behind 13 cassette tapes that explain why she committed suicide, and how 13 different people or situations contributed to it," Carlson writes. Netflix made the book into a 13-episode original miniseries that mental-health experts have criticized for many reasons, including concerns that it will romanticize the act of suicide.

Corey Sayre, a history and economics teacher at the high school, said he watched the series along with his wife, a counselor at a nearby school district. He told Carlson that the series reinforces two problems in preventing youth suicide: the main character didn't want to go to an adult, and the counselors were portrayed in an unrealistic way that reinforces the belief that kids can't trust adults.

"I don’t want kids to think that adults can’t be trusted," Sayre said. He added, "Understanding where your child’s mental health is just as important or maybe more important than knowing where their physical health is. At this age they are developing thoughts and stuff and we just have so little time with them compared to their friends or pop culture. Knowing where they are mentally and emotionally is really important.”

Carlson reports that school districts across the country have also banned the book from classrooms. Other schools have banned discussions about the miniseries.

The Kentucky Department of Education issued a warnings after the Netflix series was released that referenced comments from the National Association of School Psychologists.

“We do not recommend that vulnerable youth, especially those who have any degree of suicidal ideation, watch this series,” the organization said. “Its powerful storytelling may lead impressionable viewers to romanticize the choices made by the characters and/or develop revenge fantasies.”

The association listed a series of concerns, including:
  • The graphic depiction of bullying, sexual harassment, sexual assault, rape, and suicide can be very triggering, especially for anyone who is struggling or has struggled in the past with any of these things.
  • The show offers an over-simplified view of suicide by failing to mention mental illness.
  • There are little to no help-seeking behaviors shown by the characters. Adults are portrayed as dismissive, distracted, and unhelpful, which is a dangerous message to send to viewers.
  • Suicide contagion is also a concern since young people are more likely to attempt or die by suicide themselves after experiencing a suicide death of someone close to them.
Jefferson County Public Schools also sent a resource letter to thousands of parents in April to warn them about the miniseries and offered detailed guidance on how to talk to their children about it. It also offered a list of other resources, including: 13 Reasons Why Talking Points, Preventing Youth Suicide Brief Facts (also available in Spanish) and Preventing Youth Suicide: Tips or Parents and Educators.

The education department says suicide is the second leading cause of death for youth and young adults in Kentucky. The National Suicide Prevention Lifeline provides free and confidential support to people in suicidal crisis or emotional distress 24 hours a day, seven days a week, at 1-800-273-TALK (8255).

U.S. Rep. John Yarmuth sends letter to health secretary asking for update on Ky.'s Medicaid waiver; also urges him to not approve it

U.S. Rep. John Yarmuth
By Melissa Patrick
Kentucky Health News

In a June 15 letter, Democratic U.S. Rep. John Yarmuth of Louisville asked U.S. Health Secretary Tom Price for an update on the status of Kentucky's proposal to reshape its Medicaid program, and urged him to not approve it. The proposal went to the Centers for Medicare and Medicaid Services almost 10 months ago. Approval is expected, but it may include provisions that were not requested of the Obama administration.

Doug Hogan, spokesman for the Kentucky Cabinet for Health and Family Services, said in an email that there isn't anything to update: "We remain in negotiations with CMS on our 1115 Medicaid waiver and feel optimistic about the ultimate outcome."

Kentucky's request for a waiver from the Medicaid rules targets "able-bodied adults" who qualify for Medicaid under the expansion of the program to those who earn up to 138 percent of the federal poverty level ($16,400 for an individual).

If approved, the waiver is expected to leave the state's Medicaid rolls with 85,000 fewer people in five years than without it. The waiver proposal says it "is expected to save taxpayers $2.2 billion over the five-year waiver period," but only $331 million of that would be state tax money because the federal government is paying 90 to 95 percent of the Medicaid expansion that included able-bodied adults. This amount could change under a new Republican health plan if passed by Congress.

The bill that House Republicans passed last month to replace Obamacare, called the American Health Care Act, would end the Medicaid expansion in 2020, but Senate Majority Leader Mitch McConnell has proposed that the Senate's version of this bill -- being drafted behind closed doors -- should end the expansion in 2023.

In addition to saving money, the waiver is also meant to increase participant engagement in their health care through things like monthly premiums, volunteer and work requirements for those who aren't primary care givers and lockouts of coverage for some who fail to pay.

In the letter, Yarmuth reminds Price that under the current law, these waivers should only be approved if they further the objectives of the Medicaid program, including “strengthening or increasing coverage for low-income individuals in the state; improving health outcomes for low-income individuals in the state; strengthening providers and provider networks available to serve Medicaid and low-income populations in the state; or otherwise increasing the efficiency and quality of care provided to Medicaid beneficiaries or other low-income populations in the state.”

Yarmuth argues that Kentucky's waiver does not further these objectives because it will result in fewer people being covered than without it. He adds that "charging premiums for individuals living below the poverty line, a work requirement – which CMS has never approved – and excluding individuals from coverage for six months for non-payment of monthly premiums, among other provisions" does not further the objectives.

The letter also notes that because Kentucky is heavily rural and one of the poorest states, the waiver "will bear disproportionate personal and economic pain on our residents." Yarmuth pointed out that the work requirements for Kentuckians who live in regions with "poor job prospects" could cause them to lose their coverage and that the provisions, if approved, would make it harder for many Kentuckians with substance-use and other behavioral-health disorders to keep their coverage.

Wednesday, June 14, 2017

Medicare-Medicaid agency gives a much more favorable score to the House health bill than the Congressional Budget Office did

House Speaker Paul Ryan speaks about the bill as Majority
Leader Kevin McCarthy and others watch. (CNN image)
By Melissa Patrick
Kentucky Health News

The Trump administration has come up with its own estimate of how many Americans would lose or forgo health coverage under the bill that House Republicans passed last month, and it's a lot lower.

An actuary for the Centers for Medicare and Medicaid Services concluded that 13 million fewer people would be covered by 2026, not the 23 million estimated by the Congressional Budget Office, and that the savings to the federal budget would be larger than the CBO score.

The bill, called the American Health Care Act, passed the House 217-213. In the Senate, Republicans are working on their own version behind closed doors, and Majority Leader Mitch McConnell has said he would like to see a bill voted on before the July 4 holiday recess, but he has not delivered a draft to the CBO for scoring.

Many of the provisions in the House bill are expected to carry over into the Senate bill, but McConnell has proposed that the Medicaid expansion, particularly important to Kentucky, be phased out through 2023, not ended in 2020, as the House voted.

About 470,000 Kentuckians are on expanded Medicaid, which covers people who earn up to 138 percent of the federal poverty line. Only 82,000 are enrolled in Obamacare plans subsidized by federal tax credits.

The June 13 report from the Medicare-Medicaid agency estimates that under the House bill, 43 million Americans would be uninsured in 2026, compared with 31 million under the current law. The CBO projected that 51 million would be uninsured under the AHCA, compared with 28 million if Obamacare remained in place.

CMS projects that between 2017 and 2026, the House bill would reduce federal spending by a net more than $328 billion, "primarily because of lower Medicaid spending." The CBO projected the bill would reduce federal deficits by much less: $119 billion.

The spending reductions in the CMS report are largely a result of getting rid of several Obamacare provisions, including: $160 billion from decreased subsidies; $42 billion from elimination of the Basic Health Program, which allows states to provide insurance to those who earn up to 200 percent of the poverty level; and $383 billion from ending the Medicaid expansion of Medicaid. This is significantly lower than the CBO's estimates of $834 billion in Medicaid cuts.

The CMS estimate also accounts for $135 billion in spending to create high-risk pools for people with pre-existing conditions and age-based subsidies, which will be available to all enrollees,

The report estimates that average net premiums -- the amounts paid after federal and state subsidies are accounted for -- for subsidized plans bought on government marketplaces will be 5 percent higher in 2026 under the AHCA and the average cost-sharing amounts will be 61 percent higher, when compared to Obamacare.

CMS estimates that the House bill would cut Medicaid enrollment by 8 million people by 2026. The CBO estimated that 14 million people on Medicaid would lose their coverage by 2026.

Tuesday, June 13, 2017

McConnell defends private drafting of health bill; Paul opposes his plan to delay end of Medicaid expansion from 2020 to 2023

Majority Leader Mitch McConnell of Kentucky defended Senate Republicans' secret drafting of a new health-care law Tuesday, saying committee hearings that Democrats demand aren't needed.

"Look, we've been dealing with this issue for seven years. It's not a new thing. We've spent a lot of time on it," McConnell told reporters. "Nobody's hiding the ball here. You're free to ask anyone anything. But there have been gazillions of hearings on this subject when [Democrats] were in the majority, when we were in the majority. We understand the issue very well and we are now coming up with a solution."

Democrats continued their criticism. Michael McAuliff of Huffington Post reports, "Sen. Michael Bennet (D-Colo.) noted that McConnell had once been a strong advocate for transparency when Democrats passed Obamare after more than a year of hearings and 25 hours of debate on the Senate floor. Bennet quoted McConnell saying then: 'Above all, he said, the American people, above all, they are tired of a process that shuts them out. They are tired of giant bills negotiated in secret, then jammed through on a party line vote in the middle of the night.'"

Bennet said, “If the process we had wasn’t enough . . . what they’re giving is really giving the back of their hand to the American people.”

Some Republican senators "say the process is hard to defend, but they have no choice if they want to keep their campaign promise to replace Obamacare," Laura Litvan of Bloomberg News reports.

"We wrote a bill in the House, which nobody could amend," Sen. Lindsey Graham of South Carolina told her. "That's not good. We're trying to do it from a one-party perspective because no Democrat is willing to help us. But no, this is not the best way to do health care. But it's the way we're having to do it."

Litvan writes, "Others say they fear senators and the public will have little time to understand a final proposal when and if it is released. "I think we have to really take a look at this, and I think the American people need to take a look at it," Sen. Ron Johnson of Wisconsin told her.

"Some Republicans who have largely been left outside the deliberations say they can't predict what they'll do," Litvan writes, quoting Sen. Susan Collins of Maine: "The emerging bill is considerably better than the House bill, but saying that it's better doesn't mean that it's acceptable to me."

The main sticking point for Republicans is the future of Medicaid, which Kentucky and most other states expanded with funding from the Patient Protection and Affordable Care Act. The House bill would have ended the expansion in 2020, but McConnell has proposed a phase-out through 2023.

Bob Bryan of Business Insider reports that conservative Sens. Rand Paul of Kentucky and Ted Cruz of Texas "have also come out against a slower phase-out of this funding, making a compromise more difficult" because only 52 of the 100 senators are Republicans. They need 50 votes, plus the tie-breaker by Vice President Mike Pence.

McConnell has said he wants the Senate to pass the bill before it leaves for the July 4 holiday recess, but he wouldn't say Tuesday when it would pass. "Well, you know, I'm not going to answer that with specificity," he said. "Our goal is to move forward quickly. The status quo is unsustainable. Something has to be done. Something has to be done soon."

Meanwhile, McAuliff reports, President Trump "reportedly told GOP senators in a meeting at the White House that the repeal bill passed by the House was 'mean'." The New York Times reported likewise, citing "four congressional aides who were were briefed on the discussion and spoke on the condition of anonymity."

Politico reports Trump "made clear that the Senate needs to pass a bill that Republicans are able to more easily defend and is not viewed as an attack on Americans from low-income households, as the House bill has been portrayed by critics, the sources said. He also advocated more robust tax credits for people who buy insurance on the individual market, a move that would increase the bill’s cost."

FDA puts into limbo Obama-era nutrition labels for packaged food

"After sustained lobbying from the packaged food and beverage industry, the Food and Drug Administration announced Tuesday an indefinite delay in the launch of Nutrition Fact labels that were intended to help Americans eat more healthfully," Caitlin Dewey reports for The Washington Post. "The labels, championed by former first lady Michelle Obama, were supposed to add a special line for “added sugars” and emphasize calorie content in large, bold text. They had been scheduled for rollout in July 2018, with a one-year extension for smaller manufacturers."

Dewer notes, "The delay is the latest reversal of the Obama administration’s nutrition reforms under Trump. On April 27, the FDA also delayed rules that would have required calorie counts on restaurant menus. A week later, the Department of Agriculture loosened the minimum requirements for the amount of whole grain in school lunches and delayed future sodium reductions."

Consumer groups said the indefinite delay in the labeling change was "an attack on public health," Dewey reports. "The largest groups in the food industry, meanwhile, is celebrating what it calls a win for /common-sense' regulation. But . . . as in the case of the menu-labeling delay, some companies have already adapted to the new rules — and they may be hurt if their competitors get more time to make the change."

The early adopters include Nabisco/Mondelez, "which has rolled the labels out on its Wheat Thins crackers; PepsiCo, which has put them on Lay’s chips, Fritos and Cheetos; and KIND, which makes granola bars. Meanwhile, Mars Inc. — the maker of Uncle Ben’s rice, as well as dozens of candy brands — has vocally lobbied the FDA to stick to the original July 2018 deadline, citing consumers’ need for more health information."

Ky. ranked 34th for overall well-being of children in Kids Count report; advocates say key to improvement is to address poverty

By Melissa Patrick
Kentucky Health News

As long as more than one every four Kentucky children live in poverty, the state will struggle to improve the overall well-being of its children, says a Kentucky Youth Advocates release about the 2017 Kids Count Data Book, released Tuesday by the Annie E. Casey Foundation.

The book ranks Kentucky 34th in the overall well-being of its children, where it has hovered since 2012 when the current criteria for the measure were adopted.

“We know that economic well-being drives every other aspect of this report," KYA Executive Director Terry Brooks said. "Unless and until we get serious about changing the trajectory of poverty for kids, we will not see substantial change. While we must battle a tradition of poverty in this state, we don’t have to shrug our shoulders.”

Kentucky ranks 39th for economic well-being, down one slot from last year. Contributors for this category included 34 percent of the state's children living in homes where neither parent has secure employment; 26 percent living in households with a high housing-cost burden; and 9 percent of its teens between the ages of 16 and 19 not working or attending school.

The report did offer several bright spots, including continued improvement of Kentucky's education ranking, up to 24th from 27th last year, and fewer Kentucky teens getting pregnant.

The report offers a state-by-state assessment that measures 16 indicators to determine the overall well-being of children. The latest data are for 2015, and is compared with data from the last six or so years earlier. The report focuses on four major domains: economic security, education, health and family and community security.

Health continues to be Kentucky's highest ranking, though the state dropped four spots since last year's report, from 16th to 22nd. The state saw an increase in the number of child and teen deaths, to 31 per 100,000, up from 28 per 100,000 in 2014.

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said decreasing the state's smoking rate could decrease the number of babies born with low birth weight, which is known to increase a child's risk of short- and long- term health complications as well as being associated with impaired cognitive development. Almost 9 percent of Kentucky babies are born with low-birthweights.

“Smoking during pregnancy accounts for as many as 30 percent of low-birthweight babies,” Chandler said in the release. “The foundation is committed to ensuring healthier infants by working with advocates and local communities to promote smoke-free ordinances, ensuring that expectant mothers have easy access to effective tobacco treatment, and raising the state tax on cigarettes. Each of these strategies will reduce Kentucky’s high smoking rate. We must get serious about protecting our children from the harmful effects of tobacco.”

In education rankings, Kentucky is sixth in the nation for high-school graduation, with only 12 percent of its students not graduating on time. The bad news is that 60 percent of the state's three- and four-year-olds are not enrolled in preschool; 60 percent of its fourth graders aren't proficient in reading; and 72 percent of its eighth graders aren't proficient in math -- and these numbers haven't changed much since 2009.

Brooks optimistically looks to recent legislative changes as possible ways to improve these poor education outcomes.

"A stronger focus on career and technical education, the new potential for innovative public charter schools, differentiated career ladders for teachers, and the newly created school accountability system from Senate Bill 1, championed by Senator Mike Wilson, are all hopeful indicators that the best days for Kentucky schoolhouses are on the horizon,” Brooks said.

Kentucky dropped one spot in the "family and community" domain to 38th, a category that shows 36 percent of the state's children live in single-parent families; 11 percent live in families where the household head lacks a high school degree; and 16 percent live in high-poverty areas -- all measures that stayed about the same as last year.

However, the one measure in this category that continues to improve is the state's teen birth rate, which dropped to 32 teen births per 1,000 in 2015, from 35 per 1,000 in 2014, a 9 percent drop. And compared 2010, it's dropped by 30 percent. It remains well above the national average, 22 per 1,000.

The Kentucky Youth Advocates release calls for "common-ground solutions" to improve the well-being of Kentucky's children including: reauthorization of the Children's Health Insurance Program; implementing proven strategies to decrease smoking rates, including smoke-free laws and increased tobacco taxes; family-focused tax reforms; and investing in child welfare programs that keep families together.

“Without fundamental improvement in lifting kids out of poverty, we face a losing battle on improving education outcomes, safety, and our children’s health. Solutions abound and we are calling on the governor and the General Assembly to build a budget for children in 2018,” Brooks said.

Click on a chart to view a larger version of it.