Friday, March 31, 2017

Kentucky's last abortion clinic says Bevin is trying to shut it down, gets restraining order

Without even having a hearing, a federal judge has ordered the state Cabinet for Health and Family Services not to close Kentucky's only remaining abortion clinic.

"The order issued Friday by U.S. District Judge Greg Stivers follows a lawsuit by EMW Women's Surgical Center in Louisville seeking to block the state's effort to close the clinic over alleged deficiencies in its license," reports Deborah Yetter of The Courier-Journal. "Stivers said in his order that prior notice is not necessary in a case where facts 'clearly show' that harm, irreparable injury or damage will occur before a hearing can be held. . . . He said the clinic's lawyers had shown 'a strong likelihood of success on the merits' of their claim."

Cabinet spokesman Doug Hogan said officials were "surprised and disappointed the court entered a temporary restraining order without input from the cabinet and without first ascertaining the status of communications between both parties." Hogan added, "EMW's license was never in immediate jeopardy. The cabinet had informed counsel for EMW no final decision would be made regarding the abortion facility’s license until the administrative due process hearing required by Kentucky statutory law was complete."

The cabinet has alleged "technical" deficiencies in EMW's transfer agreements with local hospitals and an ambulance service, a condition state law sets for a license to perform abortions. It said the clinic could be closed Monday, April 3. That would make Kentucky the only state with no legal abortion services.

EMW said in its lawsuit, filed Wednesday, that its license is not deficient and that Gov. Matt Bevin is trying to abolish legal abortion in Kentucky. "The abortion clinic has had its agreements with the University of Louisville Hospital and Mercy Ambulance on file with the cabinet for several years," the Lexington Herald-Leader reports.

"Two other abortion providers ceased operations over the past year following enforcement actions by the Bevin administration," Yetter notes. "Planned Parenthood of Indiana and Kentucky suspended offering abortions at its clinic in downtown Louisville, and EMW closed a small, part-time office in Lexington . . . after the state refused to issue it a license. Planned Parenthood has appealed the state's action against its license."

Big drug bill heads to governor's desk; has harsher penalties and limits most prescriptions for acute pain to 3 days

By Melissa Patrick
Kentucky Health News

A bill that would limit most painkiller prescriptions to a three-day supply for acute pain, and change how synthetic-opioid traffickers are prosecuted, flew through the legislative process in the final days of the 2017 General Assembly. It now awaits action from Gov. Matt Bevin.

Rep. Kim Moser
photo: LRC Public Information
House Bill 333, sponsored by Rep. Kim Moser, R-Taylor Mill, would limit painkiller prescriptions such as oxycodone and morphine to a three-day supply if prescribed for acute pain, but has a long list of exceptions such as chronic pain, terminal illness and severe trauma.

"We really want prescribers to stop and think before they write that prescription for 30 Percocet or Lortabs or any narcotic, to change the mindset that opioids are the first line of treatment for pain because it may not always be necessary," Moser said in a phone interview. She is director of the Northern Kentucky Office of Drug Control Policy.

"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," Moser said. "We also know that 80 percent of heroin addicts started with either a legitimate pain prescription or opioids in tablet form, some sort of stolen medication or diverted medication."

The bill also expands jail time for the illegal possession and importing of heroin, fentanyl, carfentanil and fentanyl derivatives; increases penalties for trafficking; creates a felony offense for those who misrepresent a controlled substance as a legitimate prescription drug; and adds heroin, fentanyl, carfentanil and fentanyl derivative trafficking to aggravated trafficking in a controlled substance.

The Senate made changes to the bill to increase penalties for heroin and fentanyl, and removed the provision that enabled addicts to avoid the increased penalties, sometimes called the "peddler distinction."

The bill now requires that any transfer of heroin, fentanyl, carfentanil and fentanyl derivative to another person is a Class C felony for a first offense, with a five- to 10-year sentence and no parole eligibility until half of the sentence is served. A second or subsequent offense would be considered a Class B felony, with a term of 10 to 20 years.

Currently, "An addict caught sharing under two grams of these drugs in this way would be charged with a Class D felony with a one- to five-year sentence, with parole eligibility after serving 20 percent of the sentence" for a first offense, Ashley Spalding writes for the Kentucky Center for Economic Policy.

Writing in opposition to the changes, Spalding says the amended version of HB 333 will "lock up more addicts for longer periods of time and be ineffective in addressing the state’s addiction problems, it would be very costly for the already overburdened criminal-justice system."

Spalding argues that the changes will cost money, adding to the $30 to $35 million estimate for a similar bill (Senate Bill 14) that was not heard in the House. Spalding said it will cost more because the estimate for SB 14 assumed those trafficking in amounts of under 2 grams could be paroled after serving 20 percent of their sentence.

Moser said that without this provision, the Senate wasn't able to get enough votes to pass the bill: "They wanted zero tolerance."

She added, "This was a tough compromise for me because I really believe that you need to be able to get help for the folks who are in the cycle of addiction and not just have them stuck in this revolving door of the criminal justice system," she said, adding that prosecutors will still have discretion to determine trafficking charges.

"The real danger that we've seen is the addition of fentanyl and carfentanil with the heroin, and that's what is killing people," Moser said. "And so that's why it was important for me to pass a bill that had the distinction for fentanyl and carfentanil in it."

She said Senate Republican leaders are committed to working with the criminal justice system to continue researching whether this is the best way to handle trafficking, and whether this is best for individuals stuck in the cycle of addiction.

The bill also adds fentanyl derivatives as a Schedule I drug, meaning they have no medical use, and allows drugs to be raised to higher schedules as needed. It has language that will result in better communication between the Cabinet for Health and Family Services, its Office of Inspector General, medical licensing boards and the state Office of Drug Control Policy about prescription-drug use in the state.

The bill also excludes cannabidoiol, a non-hallucinogenic marijuana extract, from the definition of marijuana under state law if the products are approved as a prescription medication by the U.S. Food and Drug Administration. 

The bill passed out of the House 96-1 on February 28. A month later, on the next to the last day of the session, around 11 p.m., it passed out of the Senate Judiciary Committee. And on March 30, the last day of the session, it passed out of the Senate 29-9 with some changes, which the House accepted by a vote of 80-6.

Mixed reviews in the Senate

Several Senate Democrats were frustrated that such an important bill was rushed through the Senate.

"This bill could have been discussed. It's got major policy components. We could have had testimony and heard from the stakeholders affected in a public forum with civil discourse and the ability to ask questions. We didn't have that for this bill and that pains me a bit," said Sen. Robin Webb, a lawyer from Grayson, who voted against the measure.

Webb said patients with legitimate pain problems who can't get legitimate treatment "are going to go to the street, and they are going to pursue illegal means. We've seen it. We see it in our communities. I hear it in my office from time to time. And then we are upping the penalties for these individuals, when some are driven [by] legitimate sources of pain remediation."

Senate Democratic Leader Ray Jones of Pikeville said he cast a "difficult" vote for the legislation because he wanted the fentanyl and carfentanil provisions, but he agreed with Webb and said he didn't like the three-day limit. He and several other lawmakers suggested that provision should have been in a separate bill.

"That ties the hands of doctors. Those decisions should be up to the physicians," said Jones, a lawyer. "If physicians follow the current law and current standards of care, they will be able to prescribe to meet patients needs without any concern of proliferation of drugs."

Sen. John Schickel, R-Union, applauded the bill. He said the Senate had tried to pass bills to increase trafficking penalties for heroin for the past six years, since the passage of a bill that reduced prison time for the state's low-risk, non-violent drug offenders, but he said they had all died in the House when it was led by Democrats.

"A lot has been said about treatment, and I believe in treatment, but we have to keep in mind that we are, at least the majority party is, the party of personal responsibility and where I come from, people are sick and tired of hearing excuses for people dealing in heroin. Killers, murderers dealing in heroin and then those same traffickers claiming to be victims. I'm sorry, they are not victims, they are criminals and they need to be punished," said Schickel, a retired law enforcement officer.

Republican Sen. Ralph Alvarado, a Winchester physician, said he could not have voted yes for the bill without the exceptions to the three-day rule for painkillers. He said guidelines for prescribing pain medication and other controlled substances are so stringent that he, like many other physicians, have chosen to not prescribe them, which has left many of his patients in a lurch.

However, Alvarado also said it's time to reduce the number of pills on the street, and for that to happen, physicians and patients must change how they think about pain and recognize that the goal might be comfort instead of being "absolutely pain free." He said to really decrease the number of pain pills prescribed, insurance companies must stop using pain evaluation as a condition of reimbursement.

Thursday, March 30, 2017

Without dissent, General Assembly overrides governor's veto of bill allowing courts to require outpatient mental-health treatment

Mental-health advocates lobbied for "Tim's Law" outside the
state Senate chamber on March 29. (Photo by Melissa Patrick)
By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Cheers of celebration rang in both the Senate and House chambers as lawmakers overrode Gov. Matt Bevin's veto of a bill meant to end the revolving door between jail, hospitalization and homelessness for those with severe mental-health conditions.

Senate Bill 91, or "Tim's Law," would allow judges to be able to order mentally ill adults who meet strict criteria into an "assisted outpatient treatment" program, and confine them if they don't comply.

The legislation is called "Tim's Law" for Tim Morton, a Lexington man with schizophrenia who was hospitalized involuntarily 37 times by his mother because this was the only way she could get him the treatment he needed. Morton died in 2014.

Dozens of mental health advocates, dressed in red, lobbied lawmakers in support of the measure as they made their way to the Senate chambers, where it returned from the governor's office because it originated there.

"This is the culmination of so many hours and minutes and days of work and prayer and people pulling together," Sheila Schuster of the Kentucky Mental Health Coalition said with tears of joy in her eyes. "And to have come back from what looked like a defeat and now we are celebrating a victory --it made me think about what the families and the people who struggle with mental illness go through, that up and down, into the valley of despair and then back up again. It's just wonderful. It's just fabulous."

Advocates of the long-sought bill rode the legislative roller-coaster all week. First, they anticipated a signing of the bill into law by the governor, only to learn that he had vetoed it; then they quickly shifted into a whirlwind of advocacy to encourage lawmakers to override the veto; and finally enjoyed a celebration.

The bill had passed the House without dissent, and with only three "no" votes in the Senate. Without any debate in either chamber, the override votes were 35-1 in the Senate and 91-0 in the House.

Various versions of the bill have been filed in the General Assembly since 2013; this year's version has more stringent requirements.

It says a judge can only order outpatient treatment in cases where the person has been diagnosed with a serious mental illness; has been involuntarily hospitalized for mental illness twice in the past 12 months; and doesn't recognize their diagnosis or treatment needs. The person can only be ordered into treatment after a mental-health professional certifies that the law's requirements have been met.

The law will not be implemented until the state secures funding for it. Advocates have explained that the state cannot file for federal funding until the program is in place. It remains to be seen if the state will do that, in light of Bevin's opposition to the law.

Bevin''s veto said that while "well intentioned," the law "would set a dangerous precedent that would threaten the liberty of Kentucky citizens. . . . It would allow the Commonwealth to restrict the liberty of individuals based on nothing more than a finding that they are 'unlikely to adequately adhere to outpatient treatment on a voluntary basis.' Not only would this permit the restriction of liberty for individuals who have not committed crimes and do not pose a threat to anyone, but it would do so based on speculation about what might or might not happen in the future."

Schuster disagreed, saying that people with severe mental illness don't know they are ill and that this "black robe effect" will help them adhere to treatment long enough to recognize the benefit of it, explaining that while there are some provisions to address this issue that involves involuntary hospitalization, this only last between 72 hours to a few weeks, which she said is not enough time to establish long-term patient stability and more often than not creates a "revolving door" between hospitalization, incarnation and homelessness.

Schuster said this approach is an "evidence-based practice" and has been approved by the Substance Abuse and Mental Health Services Administration. Forty-four states have passed some version of this law. She said, "This bill will change the lives of families and people with serious mental illness in Kentucky."

Wednesday, March 29, 2017

County Health Rankings show troubling trend of more premature deaths, contrasting trends among some counties

By Danielle Ray
Kentucky Health News

The premature death rate is getting worse in 44 of Kentucky's 120 counties and improving in 12 counties, according to a health rankings report released Wednesday.

The figure is calculated using data from 1997 through 2014 and is part of the annual County Health Rankings & Roadmaps, released by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation.

Experts say the premature death rate is fueled by drug overdoses, which accounted for nearly 1,250 deaths in 2015, according to the Overdose Fatality Report by the Kentucky Office of Drug Control Policy.

The rate of premature death is the years of potential life lost before age 75. Every death occurring before age 75 contributes to the total number of years of potential life lost. The state average is 8,900 years, which is 1,200 years worse than the national average.

Van Ingram, executive director of the Office of Drug Control Policy, told Bill Estep of the Lexington Herald-Leader that preliminary for 2016 are about the same as the 2015 numbers, but “It’s hard to celebrate leveling off.”

Beyond the drug issue, the latest County Health Rankings have much more to say. They give each county two scores: one for health outcomes, which include premature death and low birth weight, and one for health factors, such as access to physicians and areas to exercise, children living in poverty, violent crime, long commutes and other environmental dimensions.

The highest ranked counties in health outcomes are Oldham, Boone and Spencer, respectively. Traditionally, counties with the highest rankings tend to surround cities, where there is better access to medical care and exercise opportunities, like parks, and incomes are relatively high. The lowest ranking counties tend to be poor and in rural Appalachia, and this year is no exception: Owsley, Wolfe and Breathitt.

"The rankings show that people living in Eastern and rural Kentucky counties tend to have much poorer health than those in urban Kentucky counties," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said in a news release. "The rankings also make it clear that good health is influenced by many factors beyond medical care, including whether we can find and afford healthy foods, whether we can exercise safely in our neighborhoods, whether we have health insurance and if that insurance covers preventive care, and how safe our water is to drink and our air is to breathe."

The report has been released annually since 2011. Since then, some counties have seen big improvements, while others have seen their situations worsen.

Hickman County is one of the success stories. It ranks 23rd, up by 53 spots since the initial report in 2011. Multi-year trends are important, because rankings can vary from year to year, especially in small counties like Hickman; it ranked 73rd in outcomes last year. The county's health-factors ranking has also improved, to 37th from 58th in 2011, with an increase in employment and a decrease in preventable hospital stays.

Carter County has also shown great improvement over the years. It ranked 91st for the first three years of the report, and 90th in 2014, but rose to 82nd in 2015 and 68th in 2016. This year, it ranks 57th, showing improvements in both length and quality of life.

The latest move put Carter County into the second quartile of Kentucky counties. The rankings divide the counties into four groups because the differences among closely ranked counties can be very small, within the error margins for surveys that form part of the basis for the rankings.

Some counties, such as Menifee, have seen improvements in health outcomes despite lagging ion health factors. The county's outcomes ranking bottomed out in 2013, when it placed 111th. It improved to 92nd in 2015 and 79th in 2016, and this year, zoomed to 36th. Somehow it is overcoming bad health factors, in which it ranks 97th. It has a high unemployment rate and a high percentage of children living in poverty.

Similarly, Cumberland County has steadily improved its numbers since 2014, when it reached a low outcomes rank of 107th. It improved to 102nd the following year and 97th in 2016. This year, it ranks 83rd in outcomes. Like Menifee, it still ranks lower (91st) in health factors, with too few dentists and a high number of preventable hospital stays.

Morgan County once had much higher outcome rankings than its neighbors, despite bad heath factors, and now those factors appear to be catching up with it. Morgan's outcomes ranking slipped to 91st from 76th last year and 23rd in 2011. The county's scores for both length and quality of life have steadily declined. The county also has a high unemployment rate and a high percentage of children in poverty.

For every county that moves up in the rankings, another has to take its place. Rockcastle County ranks 100th in outcomes and has experienced a steady decline since 2011, when it ranked 64th, partly due to high marks for quality of life. Since then, the county's rate of premature death has increased and its quality of life scores have decreased. It suffers from a shortage of dentists and mental-health providers, with just one for every 8,500 people, drastically lower than either state or national figures.

View an interactive map of your county's ranking, with details for each measurement, here.

Tuesday, March 28, 2017

More than half of Kentuckians have a gun in the house,15% are loaded and unlocked; among those with children, 12%

More than half of Kentucky adults have a firearm in the home and 15 percent of those guns are loaded and unlocked, according to a the latest Kentucky Health Issues Poll.

"Gun safety is a public health issue," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, a co-sponsor of the poll. "Whether it's a toddler who stumbles across a loaded gun or a teenager showing off to a friend, accidents happen every day. We can prevent these tragedies by keeping guns and bullets in separate, secure places."

The poll, taken Sept. 11 through Oct. 19, found that 55 percent of Kentucky adults had a firearm in or around the home, up from 45 percent in 2011, the last time the poll asked this question.

Asked if they had a loaded gun in the home, one in four of the gun owners said they did. Of those with a loaded gun, 10 percent said it was locked and 15 percent said it was unlocked.

among Kentuckians who had a child in the home, 59 percent also had a firearm there, compared to 44 percent in 2011. Of this group, 35 percent said it was unloaded, 12 percent said it was loaded but locked, and 12 percent said it was loaded and unlocked.

The news release noted that in 2015, 694 Kentuckians and nearly 1,500 children in America died from a firearm injury. Kentucky ranks about 26th in population but 13th in number of deaths from firearms, 15.2 per 100,000 people.

The American Academy of Pediatrics recommends not keeping a firearm in a home with a child, but if you, it says the firearm should be unloaded and securely locked in storage, away from the ammunition.

The poll found that those with higher incomes were more likely to have a firearm in the home than those with lower incomes, around 60 percent compared to 47 percent. And those living in suburbs (63 percent) and rural counties (62 percent) were more likely to have a firearm in the home, compared to those in urban counties (37 percent).

The poll was funded by the foundation and Cincinnati-based Interact for Health. It surveyed a random sample of 1,580 Kentucky adults via landlines and cell phones, and has an error margin of plus or minus 2.5 percentage points.

How Medicaid came to cover 1 in 3 people in Ky., 1 in 5 in U.S., and how it could be changed despite health bill's failure

Medicaid is the main reason many more people have health insurance, especially in Kentucky.
These New York Times maps are interactive, with county data. For the interactives, click here.
The failure of the Republican health-care bill in the U.S. House put a fresh spotlight on the importance of Medicaid, the federal-state program that covers nearly one in three Kentuckians, one in five Americans, four of every 10 U.S. children, almost half of all births and two of every three people in nursing homes.

"While President Trump and others largely blamed the conservative Freedom Caucus for that failure, the objections of moderate Republicans to the deep cuts in Medicaid also helped doom the Republican bill," Kate Zernike, report Abby Goodnough and Pam Belluck of The New York Times. "Even some conservatives . . . expressed concerns about the number of Medicaid recipients who would suffer."

Medicaid grew much larger with passage of the Patient Protection and Affordable Care Act, because it allowed states to expand the program to people with incomes up to 138 percent of the federal poverty level, about $34,000 for a family of four, with the federal government paying the cost through 2016 and states' share gradually rising to the law's limit of 10 percent in 2020.

The bill would have stopped enrollment under the expansion, so Medicaid rolls would have gradually declined as people went off the program and people who formerly would have been eligible could not enroll or re-enroll.

"It also would have ended the federal government's open-ended commitment to pay a significant share of states' Medicaid costs," the Times notes. Because Kentucky is a poor state, federal taxpayers cover about 70 percent of traditional Medicaid costs. The national average is 60 percent.

Gov. Matt Bevin's Medicaid idea resembles one Vice President
Pence enacted as Indiana governor. (Courier-Journal photo)
No matter what happens with efforts to write another bill, Kentucky, other states and the Trump administration are likely to make changes that would trim Medicaid. The administration is expected to approve Republican Gov. Matt Bevin's request for a waiver that would allow the state to charge small, income-based premiums, impose work-related requirements on able-bodied adults who aren't primary caregivers, and make other changes.

Then-Gov. Steve Beshear, a Democrat, expanded Medicaid in 2014. Most people on the expansion work, but Bevin argues it is a disincentive to work, because employment would push some beneficiaries' income beyond the eligibility limit.

Almost two-thirds of Americans said in a 2015 poll that they were on Medicaid or had a friend or family member who was, but because "many of its beneficiaries are poor and relatively powerless, Medicaid lacks the uniform, formidable political constituency that Social Security and Medicare have," the Times notes. Still, polling on the issue by the Kaiser Family Foundation has never found more than 13 percent of U.S. adults who want to cut Medicaid spending.

"The conventional wisdom that there's a great deal of stigma attached to this program does not bear out," Kaiser pollster Mollyann Brodie told the Times.

Medicaid wasn't big news when President Lyndon Johnson signed
it into law in 1965. The focus was on Medicare, which President
Harry Truman, also seated, had proposed. Others there included
Bess Truman and Lady Bird Johnson and Vice President Hubert
Humphrey. (Johnson Library photo via The New York Times)
Trump said in his campaign that Medicaid should not be cut. But he endorsed the House Republican bill, which was the party's third major attempt to end Medicaid as an open-ended entitlement, the Times notes: "The first was under President Ronald Reagan, the second was in 1995," in conjunction with welfare reform. "But this was the first time Republicans tried it while the controlled the White House and both houses of Congress."

Medicaid started in 1960 as "a small program to help the states treat the needy, as a way to stave off proposals for Medicare," the Times reports. When the Medicare-Medicaid bill passed in 1965, the latter half "almost escaped notice" and wasn't even mentioned in the Times. Congress gradually expanded it, sometimes as part of deals to cut Medicare, gradually decoupling Medicaid from the welfare system, said former Rep. Henry Waxman, D-Calif.

Then states began to expand the program, because "The assumption you could afford health insurance if you were an able-bodied adult was not true" any more, due to rising health costs, University of Chicago Professor Colleen Grogan told the Times. It reports, "Now that the law known as Obamacare has survived the effort to repeal it, more states may choose to expand Medicaid." The Washington Post reported likewise.

Monday, March 27, 2017

Colorectal cancer has declined, except in people under 30; overall, it's more common in Kentucky than in any other state

By Melissa Patrick
Kentucky Health News

Colorectal cancer has become less common since the mid-1980s, but has been increasing steadily in people younger than 50, according to a recent American Cancer Society study.

Infographic : The ColonCancer Prevention Project
Darla Carter of the Courier-Journal tells the story of Keisha Dalton, who was 30 when she noticed blood in her stool after eating spicy food and thought it was from hemorrhoids, but learned through a colonoscopy that it was cancer.

“I never thought in a million years that I would have colon cancer,” the Louisville mom told Carter. But she did.

The research, published in the Journal of the National Cancer Institute, found that while colorectal cancer rates have declined in adults age 55 and older since the mid-1980s, they increased in adults ages 20 to 39 by 1 to 2.4 percent in that period; and by 0.5 to 1.3 percent a year in adults aged 40-54 since the mid-1990s.

Rectal cancer rates increased by about 3 percent per year among people in their 20s from 1974 to 2013 and among people in their 30s from 1980 to 2013; and by 2 percent in adults ages 40 to 54 from the 1990s to 2013.

Put another way, people born in 1990 have double the risk of colon cancer and quadruple the risk of rectal cancer compared to someone born around 1950, when the risk was lowest.

The New York Times gives these numbers some perspective: "The risk of colon cancer for individuals in 1990 was 5 per million in that birth group, up from 3 per million at the same stage of life for those born in 1950. And the risk of rectal cancer for those born in 1990 was four per million, up from 0.9 million for those born in 1950."

The upward trend deserves attention, say the researchers and the Colon Cancer Prevention Project, which says one in seven colon cancer diagnoses are among people under 50.

The CCPP stresses on its website that everyone needs to be aware of the signs and symptoms of colon cancer and that providers must get an accurate family history "long before the age of 50" to make sure that people with a family history of colon cancer get screened earlier.

The study examined about 500,000 cases of colorectal cancer from 1974 to 2013. breaking down the cases by five-year age groups and by year of birth. The research does not explain the reasons for this increase in young people, but the report says increased obesity rates, poor diets, and lack of exercise are likely contributors.

And because many young people like Dalton attribute rectal bleeding to hemorrhoids and routine screening is generally not recommended for most people under 50, these cancers are often in more advanced states when they are discovered. The ACS says people under 55 are nearly 60 percent more likely than older adults to be diagnosed at a more advanced stage than those 55 and over.

The good news is that colorectal cancer rates for those older than 50 have fallen by 32 percent since 2000, while deaths from the disease fell 34 percent, likely due to increased screening, which detects and removes precancerous polyps, according to a separate study by the ACS.

This separate report notes that while every state saw a drop in colorectal cancers rates among people aged 50 and older, the slowest declines were seen in states with the highest rates, like Kentucky, which leads the nation in the incidence of colon cancer and ranks No. 4 for deaths from it.

The study authors recommend that because of this study, screening should be considered before age 50. The ACS said it is considering this suggestion.

Meanwhile, Dalton told Carter that she now educates others about colon cancer and encourages people to have open discussions with the provider, even if they are embarrassed by their symptoms or think they are too young to get cancer.

It's important to "make sure they do a colonoscopy, do any type of testing they can do, because you cannot take no for an answer," Dalton said. "This is your life. You're only getting one life."

Early colon cancer often has no symptoms, but if there are symptoms, they may include: change in bowel habits, rectal bleeding, cramping or abdominal pain, weakness and fatigue and unintended weight loss, according to the ACS. The CCPP says you can reduce your risk of colon cancer by staying active, reducing or eliminating red and processed meat, maintaining a healthy weight and stopping smoking.

Sunday, March 26, 2017

Health bill seems dead for this year, but changes are likely anyway in Medicaid and perhaps in private, subsidized insurance

By Al Cross
Kentucky Health News

What does the failure of the bill to repeal and replace the Patient Protection and Affordable Care Act, better known as "Obamacare," mean for Kentucky?

Probably not much right away, but big changes are still likely next year in the Medicaid program, the expansion of which under the 2010 law had a much larger impact on Kentucky than reform of the private insurance market.

President Trump's administration appears likely to approve major Medicaid changes for Kentucky and other states, following a model created for Indiana by a former consultant who is the new head of the federal Centers for Medicare and Medicaid Services.

The waiver requested by Gov. Matt Bevin last summer would allow the state to charge small, income-based premiums and require "able-bodied" Medicaid expansion members to work or pursue work unless they are a primary caregiver. The final waiver could include changes not originally proposed.

Kentucky's Medicaid expansion, by then-Gov. Steve Beshear in 2014, has added about 440,000 people to the program whose household incomes are no more than 138 percent of the federal poverty level, about $34,000 for a family of four.

About 82,000 Kentuckians have federally subsidized health-insurance policies issued under the 2010 law. They are guaranteed coverage for the rest of the year, and Republican leaders have indicated that the issue is dead for the rest of 2017.

Many supporters of the failed Republican bill predict that subsidized insurance will become less affordable, and that "Obamacare is in a death spiral," but the Congressional Budget Office said the individual insurance market is stable, at least nationally.

Counties in light blue have one Obamacare insurer; medium-
blue counties have two; dark-blue counties have three or more.
We will know more once insurance companies decide in two or three months whether they will offer policies on government marketplaces, and if so, in what counties and at what price. Almost half of Kentucky's counties have only one Obamacare insurer, Anthem Blue Cross Blue Shield.

Though the Republican bill failed, the Trump administration has power to influence the success or failure of Obamacare, through regulations and policies. The president has said more than once that the best political course for Republicans would be to let the system collapse, forcing Democrats in Congress to seek changes in order to avoid more blame for it.

Trump has already undermined the system by saying the Internal Revenue Service won't enforce the law's requirement that almost every American obtain health insurance. His next step could be elimination of "cost-sharing subsidies the law provides to lower- and middle-income people with marketplace plans to help pay their deductibles and co-pays," Amy Goldstein and Juliet Eilperin report for The Washington Post. "Those subsidies, which would have been erased by the House Republicans’ bill, are the subject of a federal lawsuit."

Even if Trump doesn't act, the prospect that he will make changes could further undermine the law, the Post reports: "According to health-care experts from across the ideological spectrum, an imminent question is whether the political tumult surrounding the ACA’s fate and the president’s talk of explosion could further shake the confidence of consumers and insurers alike. Doing so could prompt exits from the marketplaces."

Trump’s political posture could become “a self-fulfilling prophecy,” said Andrew Slavitt, who was acting Medicare-Medicaid administrator for the last two years of the Obama administration. He told the Post, “That’s like inheriting an overseas war, and deciding you let your own soldiers get killed because you didn’t elect to enter that war.”

But Trump is unpredictable, and after the bill's failure the White House signaled "that it may increase its outreach to Democrats if it can’t get the support of hard-line conservatives, a potential shift in legislative strategy that could affect drug prices," reports Siobahn Hughes of The Wall Street Journal.

"Chief of Staff Reince Priebus brought up the idea of working with Democrats multiple times, leaving little doubt that the White House intended to send a message to the hard-line Republican flank," Hughes writes. Interviewed on “Fox News Sunday,” Priebus said, “This president is not going to be a partisan president. I think it’s time for our folks to come together, I also think it’s time to potentially get a few moderate Democrats on board as well.”

However, Priebus's view may not prevail, because more conservative Republicans and some Trump advisers are blaming him and his fellow Wisconsin Republican, House Speaker Paul Ryan, for the bill's failure.

Several Democrats, including Beshear and U.S. Rep. John Yarmuth of Louisville, called for a bipartisan effort to improve the system. So did Republican Sen. Lindsey Graham of South Carolina. Senate Majority Leader Mitch McConnell of Kentucky didn't respond to a request for comment on those remarks.

After the bill failed, McConnell issued a statement that did not look forward: “Obamacare is failing the American people and I deeply appreciate the efforts of the Speaker and the president to keep our promise to repeal and replace it. I share their disappointment that this effort came up short.”

Most Kentucky Republicans in Congress endorsed the bill. The exceptions were Sen. Rand Paul and Fourth District Rep. Thomas Massie, who said it would have left too much of Obamacare intact.

59 percent of Ky. adults have experienced at least one adverse childhood experience, linked to physical and mental health issues

Robert Wood Johnson Foundation illustration
By Melissa Patrick
Kentucky Health News

Many health-care providers have started looking at adverse childhood experiences when assessing their patients' poor health because ACEs have been linked to risky health behaviors, chronic health conditions, low life potential and early death, and because 59 percent of Kentucky adults were exposed to at least one such experience as a child.

"There are things that happen to us early that make a huge difference in what happens to us as we get older," Dr. Connie White, senior deputy commissioner for the Kentucky Department of Public Health, said at a March 22 meeting in Frankfort to prioritize the state's top health issues.

ACEs are "potentially traumatic events that can have negative, lasting effects on a person's health and well-being, including early death," the department says. They include: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, a mother being treated violently, parental separation or divorce, substance misuse within the household, mental illness in the household, and having an incarcerated household member.

White said it is important for children to live in a secure and nurturing environment during the first two years of their life because this is when brains are "hard-wired" for social-emotional development. But she said it is just as important for children to grow up in an environment that is free of traumatic events.

"It's like building a house," she said. "There is a foundation, and if you don't start out with a very good foundation you are going to have a very unstable house."

White said children who grow up with ACEs often struggle academically and behaviorally.

"These children have impaired memory, they have an inability to concentrate, it's hard for them to stay seated, it's hard for them to follow directions, they are constantly on edge, they are easily provoked and they are impulsive because of the toxic stress they have at home," she said. "So these are children that are hard to deal with and I think the folks in our judicial system see these children all the time."

At least one program in the state is working to inform educators on how to deal with ACEs. The Louisville program, called the "Bounce Coalition," provides training on ACEs and resiliency to school staff and out-of-school activity providers in two Jefferson County public schools and will soon expand to three more and more than 500 YMCA programs this spring. This work, funded by a grant from the Foundation for a Healthy Kentucky, is expected to evolve into a state model for addressing ACEs.

Research shows that the impacts of ACEs don't end in childhood. The original ACE study, conducted by the Centers for Disease Control and Prevention and Kaiser Permanente, found a clear scientific link between many types of childhood adversity and the adult onset of physical disease and mental health disorders.

The report said that as the number of ACEs increases, so does the risk for things like alcohol abuse, chronic disease, poor work performance, financial stress, domestic violence, suicide and poor academic achievement, to name a few. It also found that people with six or more ACEs died nearly 20 years earlier than those without ACEs.

Kentucky just started surveying for ACEs on its 2015 Behavioral Risk Factor Survey. The poll found that 59 percent of Kentucky adults had experienced one or more ACEs, 64 percent had two or more and 17.5 percent had experienced four or more, higher than any other state that surveys for ACEs.

Kentucky's survey found similar results as the original national study, showing that the more ACEs a Kentucky adult had, the more likely he or she was to have smoked cigarettes, use and abuse alcohol use, bear or father children in their teens, attempt suicide during adolescence, have chronic depression as an adult, have impaired work performance, and have many chronic diseases.

"So this is an issue that I think we all need to be cognizant of so that we are not asking people what's wrong with you, but we start to think what happened to you and how did you get where you are right now," White said, noting that it is never too late for a person to learn how to be more resilient.

She added: "We can't go back and fix what's happened, but we can work on trying to figure out where people are coming from and how we can help them be better."

Saturday, March 25, 2017

Louisville's Our Lady of Peace opens first retail pharmacist-operated, long-acting injection clinic; will mostly treat opioid abuse

                               Insider Louisville photo
Kentucky is again leading the nation in finding ways to combat the opioid epidemic, as Louisville's Our Lady of Peace has become the nation's first behavioral health care center to open a retail pharmacist-operated, long-acting injection clinic, Joe Sonka reports for Insider Louisville.

Pharmacists at the clinic will provide monthly shots of long-acting medications to help patients with opioid addiction and schizo-affective disorders, and the director told Sonka that they will soon be able to provide Vivitrol shots to patients who come in with a prescription for it.

Vivitrol is a compound used to thwart addictions to opioids such as heroin. It contains a non-addictive drug that blocks the opioid from attaching to brain receptors, thus blocking its euphoric effects. The long-acting shots remain in a patient's system for 30 days.

“We’re excited about our new clinic and we’re hoping that we can make a difference in people’s lives who are undergoing addiction,” Steve Cummings, director of the new clinic, told Sonka. “And hopefully that 30 days of sobriety that the Vivitrol shot allows the patient to have will allow them to show up for behavioral health care outpatient therapy sessions sober and alert and more engaged with what they’re trying to do or not do.”

Pharmacists at the clinic will also be able to administer up to six different long-acting anti-psychotic medications for patients with schizo-affective disorders, Sonka reports.

Cummings told Sonka that the monthly shots have greater success in patients with schizo-affective disorders because these patients often stop taking their daily oral medication when their hallucinations subside, which can lead to relapse and hospitalization.

The clinic will also provide immunizations for HPV, tetanus, hepatitis B and other diseases.

Cummings estimated that pharmacists at the new clinic will be able to administer 20 to 25 shots in an eight-hour shift, and that most patients will be receiving Vivitrol.

The clinic will also hire a medication access coordinator, who will help patients and prescribers navigate the "challenges of insurance coverage and reimbursement when it comes to medication-assisted treatment," Sonka writes.

Sonka explained that one shot of Vivitrol can cost more than $1,000, and though it is covered by Medicaid and certain private insurance companies, obstacles such as prior authorization and frequent denial of claims, often keep patients from getting it.

The coordinator will also help patients schedule accompanying therapy or counseling, make sure they schedule their next injection appointment and will provide follow-up services to make sure they don't miss appointments.

Our Lady of Peace is part of the KentuckyOne Health system.

Thursday, March 23, 2017

Health officials and advocates list Kentucky's top 5 health issues, including one newly identified: adverse childhood experiences

About 125 people worked on the state health assessment at the
Kentucky History Center in Frankfort on Wednesday, March 22.
By Melissa Patrick
Kentucky Health News

A group of about 125 people spent March 22 with officials from the Kentucky Department of Public Health to prioritize the top health issues in the state, and after a long, deliberate process decided they were substance abuse, obesity, tobacco, health-care access and adverse childhood experiences.

"Adverse childhood events" such as abuse and household dysfunctions, like having a household member in jail or coming from a divorced family, can have lasting effects on health and well-being.

ACEs affect 59 percent of Kentuckians, according to the 2015 Kentucky Behavioral Risk Factor Survey, the first one to include questions about 11 such events. The results showed that Kentucky has a higher-than-average percentage of people with six or more ACEs.

"There are things that happen to us early that make a huge difference as we get older," Dr. Connie White, senior deputy commissioner of the state health department, told the gathering of about 125 people, about half of them from outside the agency.

As for the other big issues, "Eating less, good exercise and not smoking would solve so many of our problems," said Deputy Secretary Tim Feeley of the Cabinet for Health and Family Services. He said the solution to Kentucky's health problems rested in early health education and personal responsibility.

"There isn't a pill that will fix everything," he said. "We need to make people more responsible, more in tune with their own health and we need to do that through education; we need to do that through access to good health care that encourages them to do it that way."

Various health officials reviewed data on the state's health, reminding the room full of health-minded participants that Kentucky has the nation's highest smoking rate (26 percent of adults) and the highest rate of new hepatitis C infections; has seen its opioid overdose deaths triple between 2006 and 2015; is largely sedentary; and has some of the nation's highest rates of cancer, diabetes, heart disease and obesity.

One of the few bright spots in the overview was the drop in the share of Kentuckians without health insurance, from 18 percent to 7 percent since the implementation of the Patient Protection and Affordable Care Act. This was largely because Kentucky expanded Medicaid under federal health reform to those who earn up to 138 percent of the federal poverty level.

Throughout the meeting, participants expressed concerns about Republican plan to repeal and replace the Patient Protection and Affordable Care Act, which among other things would phase out the Medicaid expansion, drop the requirement to cover 10 essential health benefits and turn Medicaid into a block grant program and give the states control of it.

Allison Adams, director of the Buffalo Trace District Health Department and president of the Kentucky Health Department Association, gave an overview of Public Health 3.0. This national initiative calls for local health-department leaders to become the "chief health strategists" in their communities, focusing on prevention and social determinants of health. This new approach to public health relies on health departments working with community partners to address the health needs of their community.

Participants wrapped up the day-long meeting by forming work groups centered around each of the five identified priorities. The groups were charged to find out what is already being done in the state around these issues, and to then decide the best holistic plan to "move the needle forward."

Wednesday, March 22, 2017

The divide between dentistry and medicine can have deadly consequences; policymakers are getting more interested

(Photo from
As anyone who has ever mistakenly thought that medical insurance would cover their visit to the dentist knows, the worlds of medicine and dentistry don't overlap much.

They almost never overlap when it comes to education, insurance coverage or practice. Physicians go to medical school, and dentists go to dental school. Your doctor likely isn't concerned with whether you floss regularly, and your dentist is probably uninterested in your exercise habits.

But they probably should be, since the body doesn't know it's supposed to keep oral health problems separate from other medical issues, and the two commonly overlap. In fact, oral health problems can lead to dire medical complications if left untreated, according to the National Institute of Dental and Craniofacial Research.

Mary Otto explores this strange divide in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. One story that shapes Otto's book is the tragic case of 12-year-old Deamonte Driver, who died in 2007 after bacteria from an abscessed tooth infected his brain.

Otto discussed the history of dentistry, its practices and the cultural divide of good oral care in an interview with Julie Beck of The Atlantic magazine. She described the first push for reform in the 1920s by William Gies, a biological chemist.

"He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the health-care system. He said: 'Dentistry can no longer be accepted as mere tooth technology.' He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate," Otto told Beck.

Former Surgeon General David Satcher called for reform again in his 2000 report "Oral Health in America." "He said we must recognize that oral health and general health are inseparable," Otto said. "And that too, was a kind of challenge. And it seems like things are changing, but very slowly."

An an example of the effect of separating dentistry from medicine, Otto said more than a million Americans visit emergency rooms with dental problems each year.

"It costs the system more than a billion dollars a year for these visits," she told Beck. "And the patients very seldom get the kind of dental care they need for their underlying dental problems because dentists don’t work in emergency rooms very often. The patient gets maybe a prescription for an antibiotic and a pain medicine and is told to go visit his or her dentist. But a lot of these patients don’t have dentists. So there’s this dramatic reminder here that your oral health is part of your overall health, that drives you to the emergency room but you get to this gap where there’s no care."

Otto said that all the health-care programs we’ve had in our nation's history, including private insurance, have on some level neglected oral health or treated it as a fringe benefit. She said oral care highlights the economic inequality in America, because many dentists are focused on expensive, cosmetic procedures.

"Of course there is a lot more money to be made with some of these really high-end procedures. But on the other hand there’s this vast need for just basic, basic care," Otto told Beck. "A third of the country faces barriers in getting just the most routine preventive and restorative procedures that can keep people healthy."

Rural and poorer areas face shortages of dentists. Otto said a group of dental hygienists in South Carolina, where 250,000 children living in rural areas aren't getting dental care, fought to change state law so they could serve the needy kids without them first having to see a dentist. The dentists' lobby fought back, but the Federal Trade Commission stepped in and won the case for the hygienists "in the interest of getting economical preventive care to all these children who lacked it," Otto said.

Dentists say they're not to blame for such problems. "Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas, that we Americans need to value our care more and go out and find care more aggressively," Otto said. "They see the fault as being with society at large."

What does Otto see as the solution? She said something that needs to be discussed more in dentistry is the "Triple Aim," a concept discussed in planning for the Patient Protection and Affordable Care Act. It involves bending the cost curve toward prevention, expanding care more broadly and more cheaply, and creating a better quality of care.

"It seems like it’s capturing an increasing amount of attention from state lawmakers, governors, and public-health officials who are interested in bringing costs down for all kinds of health care and seeing that these things show promise," she said. "They're saying we’re spending too much on emergency rooms, we're spending too much on hospitalization for these preventable problems, so there are cost incentives to get more preventive and timely routine restorative care to people."

Tuesday, March 21, 2017

High-school students' research finds smokers are more likely to want to quit smoking after seeing their carbon monoxide levels

Taryn Kerley and Becca Calvert, Barren County High School seniors
Cigarette smokers who saw their carbon monoxide levels rise after they smoked were more likely to want to quit smoking, according to a study led by two students at Barren County High School, Will Perkins reports for the Glasgow Daily Times.

CO is a poisonous, colorless and odorless gas that is produced as a result of the incomplete burning of combustible products. When a person smokes, carbon monoxide enters the blood through the lungs and blocks its ability to carry oxygen to body cells.

The study, "Effects of Education and Exhaled Carbon Monoxide Testing on Smoking Cessation in a Rural Kentucky Community," was led by Taryn Kerley and Becca Calvert, both seniors who are part of the high school's nationally certified Project Lead the Way Biomedical Science program, Perkins reports.

The study included 30 participants, who ranged in age from 16 to the 50s, at a band competition.

“We would ask people who came to our table if they smoked,” Calvert said. “If they did, then we would talk to them about carbon monoxide and how it affects the body, and if they already knew that beforehand. We would ask them to rate themselves on a scale of one to 10, if they wanted to quit smoking and how much. Then we would use a smokerlyzer to get their carbon monoxide reading.”

Clavert told Perkins that participants were asked to hold their breath "for a really long time" and then blow smoke into a smokerlyzer, a device that tells how many parts per million of CO a person has in their lungs.

After the participants used the smokerlyzer, they were shown their results and asked again how they rated their desire to quit smoking, and if it had changed.

Kerley told Perkins that data showed that “there was a significant difference in the desire to quit smoking from before they saw their level to after they saw their carbon monoxide level.”

However, Kerley and Calvert said long-term smokers were less likely to change their desire to quit smoking after getting their results.

"If people had been smoking for a longer amount of time, like say, 20 to 30 years, and they smoked at least a pack a day, then they were less likely to change their desire to quit because they had gotten to a point of no return in their smoking habits," Calvert said,

Calvert also noted that the younger smokers made a game out of the smokerlyzer, trying to see who could get the highest readings, but the older participants didn't want to know how bad their results were.

Kerley and Calvert worked with Eric Fisher, assistant professor at the University of Louisville/ Glasgow Family Medicine Residency, and Brent Wright, associate dean of rural health innovation at UofL/ Glasgow FMR on their research. They presented their findings in Frankfort, along with other student researchers.

Baptist Health lays off 288, loses its CEO amid losses

Steve Hanson
Kentucky's biggest hospital operator, Baptist Health, is going through a shakeup.

The not-for-profit firm said last week that it would lay off 288 employees, most of them at its Louisville headquarters, and it announced Tuesday that its CEO for the last four years, Steve Hanson, is leaving “immediately.”

Baptist Health has been losing money for more than a year.
Baptist wouldn’t comment further, "but the organization has reported operating losses for the last five quarters, including a $28.3 million loss for the three-month period ended November 30," notes Chris Otts of "It lost $41 million in its most recent fiscal year ended Aug. 31, 2016."

“We appreciate Steve Hanson’s contributions to Baptist Health over the past four years,” Allen Rudd, the chairman of the nonprofit’s board of directors, said in a press release. He declined to be interviewed.

The release said Baptist will be led for the time being by Vice President and Chief Legal and Regulatory Affairs Officer Janet Norton and Chief Financial Officer Steve Oglesby, who have been with the firm for more than 20 years.

Baptist has eight hospitals in Kentucky (in Louisville, Lexington, Corbin, LaGrange, Madisonville, Paducah, Richmond and Elizabethtown) and recently bought Floyd Memorial Hospital in New Albany, Ind., next to Louisville. It said last week that the layoffs were not related to that $301 million purchase.

"More than three million people live in Baptist’s service area, and more than 300,000 people visited Baptist Health emergency rooms in fiscal 2015," Boris Ladwig reports for Insider Louisville. "In Kentucky, the organization ranks first in the number of admissions, cancer patients, outpatient visits and births, and second in ER visits and open heart surgeries. One out of every four babies in Kentucky is delivered at a Baptist Health facility."

Better-off Kentuckians exercise more; foundation CEO says policymakers can help increase access to exercise venues

By Melissa Patrick
Kentucky Health News

Health status and income matter when it comes to being physically active. Kentucky adults who reporting good health and higher incomes also saying they are more physically active than those reporting fair or poor health or lower incomes, according to the latest Kentucky Health Issues Poll.

"One of the things policy makers and communities can do is make it easier for residents to get exercise in their own neighborhoods," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, a poll sponsor, said in the news release. "The U.S. Office of Disease Prevention and Health Promotion says all adults should avoid inactivity, and those who participate in any amount of physical activity will gain at least some health benefits."

The poll, conducted Sept. 11 through Oct. 19, found that eight in 10 Kentucky adults said they were physically active, with 30 percent of this group reporting they were "very physically active" and 49 percent of them reporting they were "somewhat physically active."

However, these responses varied by health status and income.

Almost nine out of 10 Kentucky adults who reported excellent, very good or good health said they were very or somewhat physically active, compared to only 54 percent of those reporting fair or poor health. And those with higher incomes reported more activity than those with lower incomes, 84 percent and 76 percent respectively.

The survey also asked respondents if their neighborhood is a good place to walk, jog or bike. It found that 76 percent said their neighborhoods were excellent, very good or good for these activities, while 24 percent said their neighborhoods were only fair or poor.

But when asked if they had sidewalks and road shoulders to walk on, the results weren't as positive. Half said their neighborhoods rated excellent, very good or good for this measure and 44 percent said their neighborhoods rated fair or poor.

The survey also asked about safety for exercise; 46 percent said their neighborhoods were safe, 35 percent said they were somewhat safe and 19 percent said their neighborhood was somewhat unsafe or not safe at all for exercise.

Neighborhood exercise conditions also varied by region. Excellent, very good or good neighborhoods for physical activity were reported by 84 percent from Louisville; 81 percent from Lexington; 78 percent from Western Kentucky; 77 percent from Northern Kentucky; and 61 percent from Eastern Kentucky.

Two-thirds of Kentucky adults said increasing their level of exercise would improve their overall health. One-fourth said it would make no difference and 7 percent said it could make their health worse. This attitude varied with education. Those with more education were more likely to say that increased activity would improve their health, compared to those with less education who were more likely to say it would make no difference.

"The foundation is funding demonstration projects to improve neighborhood conditions, such as the health park in Paducah that includes a walking trail, playground and community garden. Kids who learn good physical activity habits will grow up to be healthier adults," Chandler said.

The poll was funded by the foundation and Cincinnati-based Interact for Health. It surveyed a random sample of 1,580 Kentucky adults via landlines and cell phones, and has an error margin of plus or minus 2.5 percentage points.

Sunday, March 19, 2017

Kentucky lawmakers have passed several health-related bills to deal with the opioid epidemic, and could pass several more

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The 2017 General Assembly has passed several bills meant to put more "tools in the toolbox" as the state works to combat its growing opioid epidemic.

And several more are in the pipeline to pass when lawmakers come back March 29 and 30. Those two days are provided to reconsider any bills Gov. Matt Bevin vetoes, but legislation in the pipeline can also get initial passage. It would be subject to a veto without the opportunity for an override.

Opioid-related bills that have passed:

House Bill 314, sponsored by Rep. Danny Bentley, R-Russell, would require hospitals to report positive drug tests to the Cabinet for Health and Family Services,, including results from newborn babies if the provider thinks they have been exposed to drugs. This data would be entered into the KASPER (Kentucky All Schedule Prescription Electronic Reporting) database and would give federal prosecutors, medical professionals and pharmacists access to the system.

The bill would also require hospitals and emergency departments to report all drugs with a high potential for abuse that are dispensed to patients during their stay, exempting Schedule III and IV drugs if they are dispensed for a maximum of 48 hours and not dispensed by a hospital's emergency department. The bill also requires the reporting of all positive drug tests conducted in an ER. This bill has passed both houses and been delivered to the governor.

HB 158, sponsored by Rep. Kim Moser, R-Taylor Mill, brings state controlled-substance listings into compliance with federal policy. This bill has been delivered to the governor.

Senate Bill 32, sponsored by Sen. Danny Carroll, R-Paducah, would require the Administrative Office of the Courts to forward drug-conviction data to the health cabinet for inclusion in KASPER. This bill has been delivered to the governor.

Likely to pass: 

HB 333, sponsored by Moser, would limit painkiller prescriptions such as oxycodone and morphine to a three-day supply if prescribed for acute pain, with exceptions for the terminally ill and some other circumstances.

The bill would also increase jail time for those who deal in the synthetic opioid pain killer fentanyl or any derivative of it, as well as carfentanil, which is used as an elephant tranquilizer. It would make it a felony to bring any amount of fentanyl, fentanyl derivative, or carfentanil into the state for sale or distribution. And it would create a felony offense for those who misrepresent a controlled substance including fentanyl, fentanyl derivatives or carfentanil as a legitimate prescription drug.

Also, HB 333 would ease penalties for those found guilty of selling less than two grams of heroin and excludes cannabidoiol, or CBD, products from the definition of marijuana under state law if the products are approved as a prescription medication by the U.S. Food and Drug Administration. This bill passed the House and a Senate committee and is in the Senate Judiciary Committee with two readings.

HB 305, sponsored by Moser, is meant to improve treatment options and costs associated with involuntary treatment for alcohol and drug addiction under Casey's Law.

The bill would allow a judge to order a person to undergo treatment for up to a year with the option of an additional year, and limit the costs that could be incurred by a family member or friend who asks the court to order involuntary treatment for a loved one, among other provisions. This bill unanimously passed the House, passed a Senate committee and is now on the Senate floor.

HB 308, sponsored by Rep. Addia Wuchner, R-Florence, would require Kentucky health insurers to have at least two abuse-deterrent opioid painkillers in their formulary and prohibit the substitution or dispensing of an equivalent drug product without documentation from the prescribing provider.

Abuse-deterrent opioid analgesic drugs cannot be crushed, snorted, or injected by drug abusers as readily as other opioids can. This bill passed the House and a Senate committee and has had one reading in the Senate. Bills need three readings on separate days before they can get a floor vote.

HB 145, sponsored by Rep. James Tipton, R-Taylorsville, would require age-appropriate physical and health education instruction about prescription-opioid abuse prevention and the connection between abuse and addiction to other drugs. This bill unanimously passed the House, passed a Senate committee and is on the Senate floor with two readings.

HB 454, Rep. Johnathan Shell, R-Lancaster, would require the Kentucky Department of Education and others to develop an age-appropriate drug awareness and prevention program and would require local school boards to ensure that students receive annual instruction in drug awareness and prevention, starting next academic year. The bill passed the House and a Senate committee, and resides in the Senate Education Committee with two readings.

After meeting with Trump, Rep. Andy Barr tells town meeting that he will vote 'enthusiastically' for Republican health-reform bill

Lexington Herald-Leader video

A day after meeting with President Trump, Republican U.S. Rep. Andy Barr of Lexington told constituents Saturday that he would vote for the health-reform bill proposed by leaders of his party because it is the only alternative to Democrats' 2010 reform law.

Asked if he would vote against the bill, “I’m not going to vote no on something that’s better than the status quo. I’m going to vote yes enthusiastically.”

Barr met with about 150 people at Eastern Kentucky University in Richmond, reports Kevin Wheatley of Spectrum News: "Many in the audience repeatedly jeered and interrupted as Barr defended aspects of both proposals and touched on other topics like climate change and banking reform."

The meeting came the day after Barr and several other Republicans met in the Oval Office with Trump, who said they all had been planning to vote against the bill, or "maybe" vote no. But as a result of discussions that will lead to changes in the bill, including work requirements for able-bodied Medicaid members without dependents, "Every single person in this room is now a yes," Trump said.

"Barr said the bill will lower health insurance costs for many, provide people with more choices and will eliminate a government mandate to buy insurance," Daniel Desrochers reports for the Lexington Herald-Leader.

"He said the bill keeps some popular elements of Obamacare, which he called a disaster, such as ensuring coverage for people with pre-existing conditions and allowing children to stay on their parent’s insurance plans until they turn 26. Plus, Barr said, the bill would reduce the federal deficit and would cut taxes by $600 billion."

"The audience wasn’t buying it," Desrochers reports. "They cited a report issued by the Congressional Budget Office that said about 24 million people would lose health coverage, either in the private marketplace or through Medicaid, under the Republican proposal. They also cited studies that showed the bill would significantly raise health care costs for older and low-income Americans."

Barr said the non-partisan CBO wrongly predicted enrollment under the 2010 Patient Protection and Affordable Care Act, and noted that Republicans have two more instruments to change the law: administrative regulations and a second bill that, unlike the current one, will be subject to a filibuster in the Senate.

The current bill would end the expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level. Barr's 6th District has 75,100 people on expansion Medicaid, including the son of a woman who asked Barr about her son. “If your son is currently enrolled in Medicaid, he won’t be taken off,” Barr replied.

Desrochers writes, "That is true, but many Medicaid recipients have incomes that vary from year to year and could potentially lose coverage if they take a job that doesn’t last long."

Barr told Wheatley after the meeting, "There is some concern, as was voiced in our town hall today, that older Americans who are not yet Medicare-eligible but aren’t getting health care through work, they may need a stepped-up tax credit in order to afford the higher level of costs associated with their health plan,” he said. “That is another change that could be made.”

Here is Wheatley's report:

New Medicaid boss, mentor Pence and Trump seek changes in program like some Bevin has asked her agency to approve for Ky.

Seema Verma (Getty Images)
By Al Cross
Kentucky Health News

The newly confirmed director of the nation's Medicaid program quickly served notice that she wants states to make changes like those she has helped make in Indiana and helped design in Kentucky, including work requirements. Then President Trump and key members of the U.S. House backed her up, in an effort to pass their initial bill to repeal and replace the Patient Protection and Affordable Care Act.

The Senate voted 55-43 Monday night to confirm Seema Verma, an Indiana health care consultant and protégé of Vice President Pence, to run the Center for Medicare and Medicaid Services. The next day, she and Health and Human Services Secretary Tom Price sent a letter to governors, "urging states to alter the insurance program for poor and disabled people by charging them insurance premiums, requiring them to pay part of emergency-room bills and prodding them to get jobs," Amy Goldstein reports for The Washington Post. The letter "also derides the Medicaid expansion that 31 states and the District of Columbia adopted under the Affordable Care Act."

Under Pence as governor and Verma as his consultant, Indiana expanded Medicaid, but under a federal waiver of certain Medicaid rules. Then Verma helped design a waiver request for Kentucky that would establish small, income-based premiums, impose work-related requirements and make other changes. That request is now pending before her agency, and Gov. Matt Bevin has suggested that it will not only be approved, but expanded to include other changes that the Obama administration frowned upon.

Critics of the Indiana plan say it "has been confusing for beneficiaries and some have incurred penalties through no fault of their own," reports Ricardo Alonso-Zaldivar of The Associated Press. "At her Senate confirmation hearing, Verma defended her approach by saying that low-income people are fully capable of making health care decisions based on rational incentives."

The letter from Verma and Price called for "a new era" in Medicaid "where states have more freedom to design programs." They said, "The best way to improve the long-term health of low-income Americans is to empower them with skills and employment."

However, "Such requirements would be nearly impossible to enforce, conservative and independent experts on the Medicaid program said Friday," Max Ehrenfreund reports for The Washington Post. "About 78 percent of adults enrolled in Medicaid who are not elderly live in households with at least one person working, according to an analysis by the nonpartisan Kaiser Family Foundation. Those who are not working might have good reasons for doing so, said Diane Rowland, an executive vice president at the foundation." The foundation says "about 18 percent of adult Medicaid beneficiaries who are not working are in school. Another 28 percent report that they are taking care of members of their family, and 35 percent say that they are sick or disabled." But work requirements are "a long-held goal of conservative reformers," Ehrenfreund reports.

To attract more votes from strongly conservative House members in a floor vote set for Thursday, March 24, Trump embraced amendments that the House Budget Committee said should be added to the bill. Those include allowing states to impose work requirements on healthy Medicaid enrollees who don't have dependents, Alan Fram and Erica Werner of The Associated Press report. Also, "The agreement would let states accept lump-sum federal payments for Medicaid, instead of money that would grow with the number of beneficiaries." However, "It seemed clear that GOP leaders remained short of the 216 votes they'll need, and additional changes were in the works."

Pence told a meeting of the financially conservative Club for Growth in Palm Beach, Fla., Saturday night, "We’re going to have an amendment to allow states to include a work requirement for able-bodied adults on Medicaid so we can ensure the program is there for people who actually need it." Earlier in the day, with Verma at his side, he told a crowd in Jacksonville, "We’re going to have an orderly transition to a better healthcare system in America that makes affordable, high-quality health insurance accessible for every American."

Beginning in 2020, the House Republican health-care bill backed by President Trump "would limit overall federal financing for Medicaid in the future. Taken together, those changes could leave 24 million more people uninsured by 2026, the Congressional Budget Office said Monday in an assessment," Goldstein notes. The impact would be greater in rural areas, The Wall Street Journal reports.

To see a Democratic-compiled rundown of how CBO thinks the bill would affect each of the 435 congressional districts, click here. Among Republican districts, Kentucky's 5th District has the third highest Medicaid expansion enrollment in the nation, about 105,000 out of the 440,000 expansion enrollees in Kentucky. The district also had the third largest decline in percentage of its population without health insurance, from 17.4 percent to 5.7 percent.

The 1st District, almost as rural, ranked 20th in decline of the uninsured, falling from 15.1 percent to 6.8 percent, with 76,000 in Medicaid expansion. The 2nd District was 25th, with an uninsured rate that dropped from 13.2 percent to 5.3 percent. It has 68,200 expansion enrollees. The 6th District has 75,100, the 3rd District 62,200 and the 4th District 53,000.

This story was first published on March 15 and was updated March 18, 19 and 20.