Thursday, October 19, 2017

Judge lets seven recovery clinics in Eastern and Central Kentucky re-open, but they remain under investigation

A circuit judge has ruled that seven recovery clinics in Eastern and Central Kentucky will be allowed to remain open, Jeff Noble reports for The Times-Voice in Jackson.

The Hazard, Jackson, Paintsville and Richmond clinics were raided on Aug. 29, which Noble reports resulted in five arrests at the Jackson clinic. These clinics remain under investigation by the state attorney general's office. The other three clinics are in London, Mount Sterling and Frankfort.

In issuing the temporary injunction in Breathitt Circuit Court, Judge Frank A. Fletcher wrote, “If the court does not issue a temporary injunction, the plaintiffs (The Recovery Center, LLC and Dr. George Burnette) and their patients and their employees, will suffer irreparable harm."

Noble reports that the seven clinics employ more than 78 workers and 20 contract physicians and treat more than 2,200 patients, almost all of whom receive Medicaid. All of the clinic's Medicaid payments have been withheld since Sept. 19. The judge ordered the payments resumed Oct. 16. 

Wednesday, October 18, 2017

Broad anti-smoking coalition launches with a lofty goal: adding $1 to cigarette tax in next legislative session

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- More than 100 people representing at least 84 groups gathered at the state Capitol Annex Oct. 18 to launch the Coalition for a Smoke-Free Tomorrow, with its leader boldly stating they hope to add $1 to Kentucky's 60-cent-per-pack cigarette tax in the 2018 legislative session.

"We hope that we can make some progress on this cigarette tax in this session that is coming up," Ben Chandler, chair of the coalition and president and CEO of the Foundation for a Healthy Kentucky, said. Noting that the big news of the day was a plan for the state's expensive pension crisis, he said, "We have one of the answers," revenue from the tax.

Coalition supporters displayed signs. (Photos by Melissa Patrick)
The foundation recently adopted smoke-free advocacy as its leading cause and is coordinating the coalition -- to the extent of lending it a modified version of its logo, which advocates held up during the launch.

Ellen Hahn, director of the University of Kentucky's Kentucky Center for Smoke-free Policy and a long-time advocate for a statewide ban on smoking in enclosed public places, said after the meeting that the Foundation is a "bully pulpit" that will speak for all of the advocates, and the coalition represents the federal Centers for Disease Control and Prevention's best practices for tobacco control -- increased taxes to discourage smoking, smoke-free policies, and helping people who want to quit.

"It's nice to have a fresh voice," she said. "I've said for years we need a bully pulpit. We need somebody who will speak up and say we need to do this."

At 24.5 percent, Kentucky has the second highest smoking rate in the nation, barely behind West Virginia's 24.8 percent. The national average is 15.1 percent. Almost 17 percent of Kentucky's high-school students are smokers, more than double the national average of 8 percent. Nearly 9,000 Kentuckians die from cancer or another smoking-related illness each year, and the state spends about $2 billion annually on smoking-related health care.

"Welcome to the cancer capital of the nation," Chandler said, noting that cancer hasn't declined as much in Kentucky as it has nationally, and cancer rates are increasing in parts of the state. He said the high smoking rate is partly to blame.

The coalition has set three goals: the $1 increase in the cigarette tax, with parallel increases in taxes on other tobacco products; helping counties and cities enact comprehensive smoking bans; and educating the public and health-care providers about a new law that requires health insurers to provide barrier-free coverage for all federally approved tobacco-cessation medications and programs.

Ben Chandler, president/CEO, Foundation for a Healthy Ky.
"These are proven laws and policy changes that will reduce our smoking rates, that will reduce our health care costs, that will in fact improve our health," Chandler said. "What's more, these policy changes don't cost an arm and a leg. In fact, they can dramatically improve Kentucky's troubling budget situation."

Chandler said Republican Sen. Stephen Meredith, a retired CEO of Twin Lakes Regional Medical Center in Leitchfield, has told him he plans to pre-file a bill to raise the cigarette tax by $1.

The current 60-cent tax is about a third of the national average of $1.71 per pack. The coalition projects that a hike to $1.60 a pack would bring in $266 million the first year.

Republican Sen. Ralph Alvarado, a Winchester physician who has sponsored several unsuccessful smoke-free bills, including one last session to make schools and school activities smoke-free, says he thinks the timing could be ripe to pass a cigarette tax because the pension system needs more money and Gov. Matt Bevin wants to reform the state's tax system.

Sen. Ralph Alvarado, R-Winchester
"The governor has charged that everything will be on the table when it comes to this tax proposal, so consequently now is the time to start looking at proposals that by themselves maybe would not pass, but as part of a larger reform has a chance to become law," Alvarado said.

Chandler said anything less than a $1 increase wouldn't work because it could be absorbed by the tobacco companies through things like temporary price cuts or other promotional discounting. He also noted that it has to be high enough to make people want to quit. "Otherwise it's just a tax increase with no health benefits, and what we care about are the health benefits,"he said.

Skeptics of a cigarette-tax increase say its revenue would decline as more people stop smoking, but Chandler said "We don't think it'll decline a whole lot," based on other states' experience. "Of course, the more it declines, the better. Any decline that does take place in the revenue the state receives is more than made up in savings on health-care cost. Anyway you look at it, it is a win for the state budget."

David Adkisson, president and CEO of the Kentucky Chamber of Commerce, said 90 percent of the chamber's members support a statewide smoking ban and legislation that would increase the cigarette tax. He added that the the costs of smoking to employers, in extra health care costs and reduced productivity, is almost $6,000 per smoking employee each year.

Jacob Steward of Bourbon County High School won applause.
"Our smoking situation in Kentucky is not only killing us, it's bankrupting us," he said.

Jacob Steward, a sophomore at Bourbon County High School and a member of a group called Students Making a Community Change, said he thought the additional tax would "significantly help" teenagers quit smoking because they would no longer be able to afford them, but he also suggested that it's also important to figure out why they ever started smoking in the first place.

"I think that one thing that should come out of this is maybe better outreach for those students. For people to actually empathize with them and understand why they started smoking to begin with," he said to a room full of applause.

Dr. Patrick Withrow, a cardiologist and director of public outreach for Baptist Health Paducah, held up a huge model of a cigarette and called it one of the most effective drug-delivery devices.

"Raising the price of cigarettes is the single most effective thing we can do to decrease smoking in Kentucky. If we decrease smoking in Kentucky, we decrease smoking disease, we decrease smoking death, and we improve quality of life," he said.

Chandler said the coalition will work systematically to help communities across the state become smoke free, with the long-term goal of passing a statewide smoke-free law. "Ultimately the goal is to get a critical mass of communities," he said. "We have 33 percent of the population covered right now; we'd like to raise that considerably and at that point maybe the state legislature might be ready to pass a statewide law."

The state House passed a smoking ban in 2014, but the bill died in the Senate, and Bevin, who took office in 2015, says smoking bans should be a local issue.

Chandler, who ran for governor as attorney general in 2003 and was 6th District U.S. representative from 2004 through 2012, was asked how hard politically it would be to pass the $1-a-pack tax increase.

"We are not overly sanguine about it. We do live in Kentucky and I think we all understand that, but things are changing in Kentucky," he said, noting that there are only 4,500 tobacco farmers in the state, down from almost 60,000 in 1992. "You are seeing a lessening of the economic impact, a lessening of the number of people who benefit from tobacco, and I think all of those things ought to come together to make this a more propitious time to get these things done."

Alvarado said opponents of the tax acknowledge that its day will come. He noted the state's budget problems and said,"It will be an accomplishment with the largest health impact for our state, and that's why we have to keep chasing the prize as a group."

Chandler concluded, "Folks, we are not going away until we succeed. We are not going away until Kentucky's smoking rate is no longer the highest in the nation. We are going to keep at it until we win this battle because our work is a win for public health, it's a win for Kentucky's budget and it's a win for Kentucky businesses."

Tuesday, October 17, 2017

Trump has mixed messages on Obamacare subsidies deal; McConnell is noncommittal, and some in GOP oppose it

UPDATE, Oct. 18: White House Press Secretary Sarah Huckabee Sanders said Wednesday that President Trump is opposed to the deal as it now stands. Sen. Lamar Alexander said he expected the deal to become law by the end of the year.

"A pair of leading Republican and Democratic senators reached an agreement Tuesday to fund key federal health-care subsidies that President Trump ended last week — and the president expressed support for the plan," The Washington Post reports. But it remains to be seen whether Majority Leader Mitch McConnell, other Republican Senate leaders, and leaders of the House's Republican majority, would go along.

“We haven’t had a chance to think about the way forward yet,” McConnell said at his weekly news conference, "minutes after the deal was announced about 20 feet away outside a Republican policy luncheon," Sean Sullivan and Juliet Eilperin report for the Post.

Just last week, Trump cut off the subsidies, which reimburse insurance companies for reducing out-of-pocket costs such as co-payments and deductibles for lower- and moderate-income Obamacare policyholders. Tuesday, he said of the deal, “It’ll get us over this intermediate hump,” and called it “a short-term solution so that we don’t have this very dangerous little period.”

Insurers have said that without the subsidies, "premiums for many customers purchasing plans under the Affordable Care Act would shoot up, and with profits squeezed, some of the companies would probably leave the market," The New York Times reports. That could leave some counties, especially in rural areas, without any Obamacare insurers.

The deal between Sens. Lamar Alexander of Tennessee and Patty Murray of Washington, the Republican chairman and ranking Democrat of the Senate health committee, would give states more flexibility in Obamacare. For example, Alexander "said the proposal would offer states greater freedom by allowing them to make changes to insurance offerings as long as the plans had 'comparable affordability,' which is a slightly looser definition than the existing one."

"For Democrats, not only would the cost-sharing reductions be brought back, but millions of dollars would be restored for advertising and outreach activities that publicize insurance options available in the health law’s open enrollment period, which starts next month," the Times reports. "The Trump administration had slashed that funding."

“We will spend about twice as much or more than President Trump wanted to expend,” Alexander said. “This agreement avoids chaos, and I don’t know a Democrat or a Republican who benefits from chaos.”

But the path forward remained unclear. The House is in recess week, and a spokesman for Speaker Paul Ryan declined to comment, but some leading House conservatives objected to the plan, and Rep. Tom Cole (R-Okla.), a close ally of House GOP leaders, told the Post, “None of our guys voted for Obamacare. They’re not very interested in sustaining it.” UPDATE, Oct. 18: House Speaker Paul Ryan, "reflecting his most conservative members, came out against the deal on Wednesday," the Times reports.

Across the Capitol, "Many Republican senators are distancing themselves" from it, the Post reports. However, Thomas Kaplan and Robert Pear of the Times report: "Sen. John Thune of South Dakota, a member of the Senate Republican leadership, said there would be 'a sense of urgency to move a bill,' since Mr. Trump intended to stop the payments right away."

Neonatal Abstinence Syndrome conference to be held Nov. 10 at Northern Kentucky University; it's free, but registration is required

Northern Kentucky University is hosting a conference Nov. 10 that will convene researchers from across the Ohio River together to discuss neonatal abstinence syndrome: addicted babies.

The conference, which organizers hope will be an annual event, will be held from 9 a.m. to 4:45 p.m. in Room 107 of the NKU Student Union in Highland Heights.

The conference will focus on evidence-based research into neonatal abstinence syndrome, with the hope of increasing collaboration among NAS researchers.

Vice News chart
As part of a series of stories on opioid addiction called A Nation in Recovery, Keegan Hamilton of Vice News writes that NAS "has overwhelmed the medical system, and many intensive care units for newborns are at capacity." The rate of babies being born with NAS has increased 400 percent since 2000, with one baby born with the syndrome every 25 minutes. In Kentucky, one out of every 50 newborns has NAS.

The keynote speaker for the conference will be Judith Feinberg, a professor of behavioral medicine and psychiatry at West Virginia University, who will present "The Opioid Epidemic: A view from the Belly of the Beast."

Other topics include the state of research on NAS, and what is left to find out; what communities can do about the opioid epidemic; and opioids through the eyes of a physician.

Sam Quinones, author of Dreamland: The True Tale of America's Opiate Epidemic, will wrap up the day in a conversation led by NKU Provost Sue Ott Rowlands. In a visit to the campus last year, Quinones challenged the region to develop collaborative efforts to battle the opioid epidemic.

"As part of the response to that challenge, NKU has been leading the effort in working with universities to establish ORVARC,” Rowlands said in a press release.

Quinones was the keynote speaker at the most recent Foundation for a Healthy Kentucky policy forum, where he talked about the importance of re-building communities as part of the ultimate solution to the opioid epidemic.

"Heroin is the perfect symbol for how isolated we have become as Americans, and how much we have killed off or ignored what would bring us together," he said. "I believe therefore more strongly than ever that the antidote to heroin is not Naloxone, it is community."

Registration for the conference is free, but required. Click here to register. Click here for the conference schedule.

Monday, October 16, 2017

Surgeon and health researcher goes home to Appalachia to ask, 'Is health care a right?' and gets differing, evocative answers

Dr. Atul Gawande
"Is health care a right?"

So asks Atul Gawande, a surgeon and public-health researcher, in an article for The New Yorker, after asking it of people in his hometown of Athens, Ohio, in the foothills of Appalachia.

He found that even those who lean toward thinking health care is a right still struggle with the idea of "undeserving" people getting something for free. That means Medicaid, the main instrument of the Patient Protection and Affordable Care Act in Kentucky.

One middle-aged Ohio couple, who had private insurance with a $6,000 deductible and a hefty co-pay and premium, told Gawande that their many health issues had caused them to file for bankruptcy.

And while they both said they leaned conservative, the husband, called Joe, maintained that access to health care is a right, but shouldn't be free. But his wife, called Maria, was conflicted. She said her liberal side believes that "people should be judged by how they treat the least of our society," but her conservative side believes that because "I work really hard, I deserve a little more than the guy who sits around."

Gawande writes that "a right makes no distinction between the deserving and the undeserving," but said this concept "felt perverse" to Maria and Joe.

“I see people on the same road I live on who have never worked a lick in their life,” Joe told Gawande, his voice rising. “They’re living on disability incomes, and they’re healthier than I am.”

Joe stressed that he would be willing to help people who tryto help themselves, but had no desire to help a person who has "spent his whole life a drunk and a wastrel." Gawande writes that "such feelings are widely shared."

But not by everyone. Gawande's friend Tim Williams, a cancer survivor who went three years without a job after chemotherapy and now works as the operator of the town's water-treatment plant, told Gawande that health care is like water: necessary for human existence, and therefore the government has the responsibility to provide it.

Monna French, a 53-year-old librarian at the middle school in Athens, said she had largely taken care of herself and her two children after her divorce, and eventually landed a job at the library that offered health insurance. Calling herself a conservative, she said the idea of health care as a right is just another way to undermine work and responsibility. “If you’re disabled, if you’re mentally ill, fine, I get it,” she told Gawande. “But I know so many folks on Medicaid that just don’t work. They’re lazy.”

But when Gawande asked French and others about Medicare, the program for all people 65 and older, they were all on board -- largely because everyone who works pays into it. Medicaid, funded by federal and state taxes, is open in Kentucky to people with incomes up to 138 percent of the poverty line. At 139 percent, they must rely on private insurance, which they may not find affordable.

French, whose husband is on Medicare, told Gawande, “I believe 100 per cent that Medicare needs to exist the way it does.” Gawande writes, "This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get."

Gawande says this understanding could be the key to the current political impasse over Obamacare, because a system that gives everyone a different deal is having a "corrosive effect" on America. He drew insight from another childhood friend, artist Arnold Jonas, who pays his bills by working as a mechanic or manual laborer.

Jonas said he doesn't consider health care a right, but does think health policy should be centered around security. For example, he noted that the fire department and police provide security to all of us, and said health care should be the same -- through "collective effort and shared costs." However, he added, "When people get very different deals on these things, the pact breaks down."

Gawande also tells the story of a friend who had been opposed to Obamacare, but after having a heart attack realized the importance of its guarantee that insurance policies cover pre-existing conditions.

Gawande writes in detail about the history of health insurance; he notes the growing "gig economy" that has moved many Americans away from the traditional employer-insurance model; the move away from one of America's fundamental concepts of "shared belonging, mutual loyalty and collective gains;" the high cost of health care, and how that further divides the haves and the have nots; and the divisions that exist around what kind of health care America should have.

"Few want the system we have, but many fear losing what we've got," he writes, adding later, "What we agree on, broadly, is that the rules should apply to everyone."

Sunday, October 15, 2017

Registration is open for Covering Health: a News Workshop, free of charge to all journalists, in Madisonville Friday, Nov. 10

On Friday, Nov. 10 in Madisonville, the Institute for Rural Journalism and Community Issues and the Foundation for a Healthy Kentucky will present the latest in their series of workshops to help local journalists cover health care and health in Kentucky.

The presenters will include Al Cross, director of the institute and editor-publisher of Kentucky Health News; KHN reporter Melissa Patrick, a former nurse; Dr. Ellen Hahn of the University of Kentucky College of Nursing, who directs the Bridging Research Efforts and Advocacy Toward Health Environments (BREATHE) program; and Wayne Meriwether, CEO of Twin Lakes Regional Medical Center in Leitchfield, a leader of the Population Health Committee in Grayson County.

"Covering Health: A News Workshop" will run from 9:30 a.m. to 4 p.m. at the Ballard Convention Center, near the KY 70 interchange with Interstate 69 (formerly the Pennyrile Parkway). Lunch will be served, and the event will be free of charge, thanks to support from the foundation.

"We hope many reporters and editors who cover Western Kentucky will spend a few hours with us to learn how their reporting can help their readers, listeners and viewers live healthier lives and better understand the health-policy debates going on in Frankfort and Washington," Cross said. "We also invite their suggestions for the program."

The program will include:
  • Information about the major health issues facing Kentucky, with special attention to Western Kentucky and the counties represented by the attendees
  • An explanation of the Medicaid program and the changes that the administration of Gov. Matt Bevin wants to make (and which may be federally approved by Nov. 10)
  • An explanation of health insurance under the Patient Protection and Affordable Care Act ("Obamacare") and the issues in play in Congress and the Trump administration
  • How to gather and use health data on your county to do stories that help your readers, viewers and listeners realize the depth of the health issues facing your community
  • How drug abuse has become less of a law-enforcement issue and more of a health issue, and the issue of syringe exchanges to prevent outbreaks of HIV and hepatitis C
  • The impact of tobacco on Kentucky's health and the issues around local and state laws to limit smoking
  • How a local health coalition in Grayson County won passage of smoke-free ordinances
  • How to cover local health issues, including your health department, health board and hospital
While the workshop is free, registration is required, and the deadline is Friday, Nov. 3. To download a registration form, click here. For a report on last year's workshop, in Eastern Kentucky, click here.

Congress helped drug manufacturers loosen federal oversight of opioid shipments, '60 Minutes' and The Washington Post report

After years of being lobbied by drug manufacturers, Congress last year stripped the Drug Enforcement Administration of its most effective tool to police drug distributors, “even as the opioid epidemic raged and thousands of Americans were dying of overdoses.” So says The Washington Post, introducing its report of a joint investigation with CBS's “60 Minutes” found.

"A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills," the Post reports. "The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns."

The CBS report says Kermit, W.Va., pop. 392, just across the state line from Warfield, Ky., received 9 million hydrocodone pills over three years. The main distributor in Mingo County was Miami-Luken Inc. of Springboro, Ohio. "Many went to one pharmacy in Williamson, the county seat, population 2,924," the Post reports. "In one month alone, Miami-Luken shipped 258,000 hydrocodone pills to the pharmacy, more than 10 times the typical amount for a West Virginia pharmacy. The mayor of Williamson has since filed a lawsuit against Miami-Luken and other drug distributors, accusing them of flooding the city with pain pills and permitting them to saturate the black market."

Sen. Joe Manchin (D-W.Va.) has asked Trump to withdraw Marino's nomination of the bill's prime sponsor, Rep. Tom Marino (R-Pa.) to be director of the White House Office of National Drug Control Policy, or drug czar. Manchin said he was "horrified" by the Post-CBS report. "Marino’s staff called the U.S. Capitol Police when the Post and '60 Minutes' tried to interview the congressman at his office on Sept. 12," the Post reports.

The bill requires the DEA to show that a “substantial likelihood of an immediate threat” of death, serious bodily harm or drug abuse before it can freeze drug shipments. It passed the House and Senate by unanimous consent, a non-debating procedure usually "reserved for bills considered to be noncontroversial," the Post reports.

"The White House was equally unaware of the bill’s import when President Barack Obama signed it into law, according to interviews with former senior administration officials." However, the Post and CBS report that Attorney General Eric Holder warned that an earlier version of the bill would undermine DEA's ability to block suspicious drug shipments. Obama and Loretta Lynch, attorney general at the time, declined to be interviewed.

Joe Rannazzisi, former DEA official (CBS News photo)
Near the start of the process, Joe Rannazzisi, who ran DEA's program to keep drugs from being diverted for illegal purposes, told congressional staffers, "You'll be protecting criminals." DEA's already poor relationship with Congress went downhill, the bill passed the House, the DEA administrator resigned for unrelated reasons, Rannazzisi lost his job, and the agency "was forced to accept a deal it did not want" in the Senate, CBS reports. "The new law makes it virtually impossible for the DEA to freeze suspicious narcotic shipments from the companies."

The bill was steered through the Senate by Sen. Orrin Hatch of Utah. It was drafted by a former DEA lawyer who went to work for drug companies and now works for Cardinal Health, the distributor that pushed back earliest and hardest on DEA enforcement efforts. DEA had fined Cardinal Health and McKesson Corp. millions for filling suspicious orders. AmerisourceBergen is the other major drug distributor in the U.S. CBS's Bill Whitaker asked Rannazzisi, "These big companies knew they were pumping drugs into American communities that were killing people?" Rannazzisi replied, "That's a fact. . . . This is an industry that's out of control."

The Post reports, "The DEA and Justice Department have denied or delayed more than a dozen requests filed by the Post and '60 Minutes' under the Freedom of Information Act for public records that might shed additional light on the matter. Some of those requests have been pending for nearly 18 months. The Post is now suing the Justice Department in federal court for some of those records."

October is health literacy month, and the revived Health Literacy Kentucky wants you to know it's a topic that affects everyone

By Melissa Patrick
Ketnucky Health News

Most states do not have have an organization dedicated to health literacy, but Kentucky does, and it's spending 2017 re-branding itself and letting Kentuckians know what it offers.

Health Literacy Kentucky is a statewide coalition of volunteers who work toward improving the state's health outcomes through improved health literacy.

"Health literacy affects everyone and is critical in helping us make choices for the best health that we can -- for ourselves and for our family and friends," Charles Jackson, The Humana Foundation's consultant for the initiative, said in an interview with Kentucky Health News.

Jackson, who is also the head of the HLK steering committee, noted that the American Medical Association says "Health literacy is a stronger predictor of health than age, income and employment status, education or race."

HLK's website says the impact of low health literacy is well-documented. It says people with poor health literacy have overall poorer health, higher rates of emergency-department use, lower use of preventive services and increased difficulty managing their chronic conditions. It adds that poor health literacy cost the nation up to $238 billion every year.

HLK was founded in 2009 and has focused most of its past efforts and resources hosting an annual health literacy conference that largely targeted health care providers. But this year, Jackson said it's working to re-brand itself and increasing public awareness -- and it also has a new partner.

In June, HLK signed a memorandum of understanding with the Center for Health Service Research at the University of Kentucky, which will now house the organization and offer it administrative and operational support. Center Director Mark Williams, who has done research on health literacy since 1990, said they expect this partnership to be a "powerful" one.

"Health literacy encompasses far more than just literacy. It represents an individual’s ability to obtain and use health information to make decisions," Williams said. "Through this partnership with Health Literacy Kentucky, the UK Center for Health Services Research can support efforts to work with patients, their family caregivers and community providers to address health literacy education and research."

Jackson noted that one of their first efforts as partners will be to conduct a heath-literacy needs assessment of health professionals to help inform future HLK strategies.

Another new initiative for the organization is its first Kentucky Health Literacy Award, of which it will soon call for nominations. The award will be presented at the Dec. 5 Kentuckiana Health Collaborative forum in Louisville, which will focus on health literacy. The results of the needs assessment survey will also be announced at this forum.

Elizabeth Edghill, who is also on HLK's steering committee, says the need for health literacy is "profound" for everyone.

"We need to recognize that it's not about education, it's not about income or language barriers," she said. "Those are all huge contributors and of course they can make one at higher risk for low health literacy, but I really think we have to use what we call a universal precaution approach. We need to assume that anyone can be having a low health literacy moment at any encounter and treat them respectfully and with good communication."

Edghill is a registered nurse who is the manager of refugee and immigrant services for Family Health Centers in Louisville. Along with a co-worker, she has initiated several health-literacy programs, including one for all of the center's patients; one that involves a patient advisory group that helps create better health related materials, and another that focuses on health-insurance literacy.

Asked how individuals could immediately improve their health literacy, Edghill said: "One of the most important ways to improve your health literacy is to find a way to record the information."

Edghill told a story illustrating how three people can hear the same health information from a health-care provider and leave with three different interpretations. She offered several suggestions on how to record information, including asking the provider if you can record the conversation; taking notes during the visit; taking someone with you to listen and take notes; or to make sure you understand the after-visit summary that is often provided before you leave the office.

Edghill has been named the 2017 Medi Star Dickinson Wright Nurse of the Year, an award  she will receive Oct. 24 in Louisville.

Jackson said health departments and libraries are great resources to improve health literacy. "Those are the kind of resources we want people to feel comfortable using," he said.

He also noted some free online resources, which he said are important for areas with poor access to health care. They include "Learning About Diabetes;" "The Depression and Bipolar Support Alliance;" and another for children who are overweight or obese called "Weigh2Rock."

Also, the HLK website offers resources for individuals and communities, a "tools for teaching" page, a free online course with continuing-education credits, and training for health-care providers.

Williams noted that the UK Center for Health Services Research was awarded a $4.5 million grant in July to identify and address the social determinants of health in 27 Appalachian counties and parts of Louisville Metro. He said that after determining the most vulnerable patients in these areas, the researchers will then  identify their unmet social needs that contribute to poor health, like unstable housing or a lack of transportation, and then connect them with  community resources to meet these unmet needs.

"This is related to health literacy," he said, "because these patients on their own don't have the health literacy skills to be able to find these resources which could help them personally, and that results in improved, overall health."

Free symposium on aging and dementia has sessions for health industry at UK Nov. 3, general public at Lexington Center Nov. 4

Want to know more about Alzheimer's disease and other forms of dementia? The seventh annual Markesbery Symposium on Aging and Dementia offers opportunities for people in the health-care industry on Nov. 3 and for the general public on Nov. 4.

The scientific symposium and poster session will be held from 10 a.m. to 3 p.m. Friday, Nov. 3, in the Pavilion A Auditorium of the University of Kentucky's Albert B. Chandler Hospital.

The community session will be held from 8:30 to noon Saturday, Nov. 4, at the downtown Lexington Convention Center's Bluegrass Ballroom. It will include an "ask the experts" question-and-answer session, and a free continental breakfast.

Both sessions are sponsored by UK's Sanders-Brown Center on Aging, but registration for them is separate, at http://www.uky.edu/coa/.

Dr. Linda Van Eldik, director of the center, writes in the Lexington Herald-Leader, "Why do some people stay intellectually sharp into their 90s, while others have memory problems? Is there anything we can learn from their lifestyles that can help everyone age successfully? Typically we focus on who gets dementia and why, but we can learn just as much from the people who don’t get Alzheimer’s." She mentions the two keynote speakers:
▪  Dr. Claudia Kawas of the 90+ Study follows the fastest-growing age group in the U.S.: “the oldest old.” Dr. Kawas appeared in a 2014 “60 Minutes” episode called Living to 90 and Beyond that explored the secrets to a long and happy life.
▪  Rachel Whitmer, a national expert on risk factors for dementia, including obesity and diabetes. Dr. Whitmer was also featured on “60 Minutes” in a 2016 story about an extended family in Colombia with a genetic mutation that causes Alzheimer’s disease.
"Dementia is a disease, not an inevitable part of aging," Van Eldik writes. "There is much you can do to reduce your risk of getting Alzheimer’s or other dementias. "Information at the Markesbery Symposium will empower you to take control of your life and maximize your ability to age successfully."

Saturday, October 14, 2017

Sen. Paul says Trump order will lead to health-insurance access for millions; Rep. Yarmuth says it will lead to 'junk plans'

After signing the order, Trump got a thumbs-
up from Paul. (New York Daily News photo)
By Melissa Patrick and Al Cross
Kentucky Health News

With Congress stymied, President Trump took two steps to undermine the Patient Protection and Affordable Care Act, one with U.S. Sen. Rand Paul of Kentucky at his side.

Trump signed an executive order Oct. 12 to make it easier for people to buy health insurance through associations, increase the length of time a person can be on a short-term insurance plan, and expand the flexibility of health reimbursement accounts.

Hours later, Trump said he would stop paying cost-sharing subsidies that reduce out-of-pocket expenses for low- and moderate-income people with Obamacare plans, about 40,000 in Kentucky.

Critics said both steps would further destabilize the Obamacare market, and several attorneys general, including Kentucky's Andy Beshear, filed suit to restore the cost-sharing subsidies.

Paul, a long-time advocate of association health plans, told reporters in a phone call that allowing individuals to join associations across state lines will increase their purchasing power to bring down the cost of insurance and get more people covered.

"We think we can drive prices down, and then some of the people -- there are 28 million people in our country who still don't have insurance under Obamacare -- then some of those people could find insurance that is less expensive and also that some of the ones on the individual market, the 11 million on the individual market, could find less expensive options also," he said.

U.S. Rep. John Yarmuth
But Democratic U.S. Rep. John Yarmuth of Louisville said the change would let insurers "build a huge market of junk plans, which will return us to the days where American families are one major illness or accident away from bankruptcy. Under these plans, insurers can deny coverage to people with pre-existing conditions, meaning only people who are currently healthy will buy them."

That, Yarmuth and other critics said, will further burden Obamacare plans with less-healthy people, driving up their claims and premiums. "Insurance markets that provide real coverage with real protections will collapse," Yarmuth said. "Welcome to Trumpcare."

Association health plans are likely to be cheaper because they wouldn't have to cover the 10 essential benefits required by Obamacare, such as hospitalization and substance-use disorders.

Asked if association plans would make premiums rise for those left in the more regulated market, Paul said, "The interesting thing is that these new groups will not discriminate. They will take all comers, and . . . group insurance already requires that you can't discriminate based on pre-existing conditions." However, short-term plans allow such discrimination.

He said larger association health plans would have a mix of healthy and less healthy participants, which would keep costs down. However, critics warned that smaller associations could fail if hit with large claims.

Trump's order also allows employers to give workers money to buy their own coverage through health reimbursement accounts, and extends the length of time short-term plans can offer coverage from three months to one year. The order will not affect open enrollment for coverage in 2018, which begins Nov. 1.

Association health plans are usually membership groups based on a profession or business, which proponents say "gives them more clout with insurers," resulting in lower premiums, writes Julie Apleby of Kaiser Health News. She says the big savings from these plans will likely be a result of "bare-bones" policies that Obamacare outlawed. Savings would also come from plans that set premiums based on the health of the group, something not allowed for Obamacare-compliant plans.

Some groups, like the National Federation of Independent Business, have long supported expanding these plans, but other small businesses have opposed them, saying that a small-group market already exists in Obamacare and an influx of association health plans would weaken that market by chasing people out of it.

Consumer advocates expressed concern that "unwary consumers" could be surprised by large medical bills, and the National Association of Insurance Commissioners issued a statement opposing expansion of association health plans.

"The NAIC has long expressed concerns with expanding AHPs in a manner that reduces consumer protections or solvency requirements that promote safe and sound markets," said NAIC President Ted Nickel, who is also Wisconsin's insurance commissioner. "We also have concerns about the impact of such a proposal on already fragile markets."

Cost-sharing reductions

Senate Majority Leader Mitch McConnell of Kentucky issued a statement endorsing Trump's order, but was mum about the president's elimination of the cost-sharing subsidies.

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) have been working for months on a bill to give states more flexibility in implementing Obamacare and fund the subsidies, which are authorized by the law but have not received appropriations form Congress. President Obama used other means to pay them, but a court has ruled against that, and the case is on appeal.

"Defiant Democrats, convinced they have important leverage, promised to press for a bipartisan deal to restore the money by year's end," The Associated Press reports. "That drive could split the GOP. On one side: pragmatists seeking to avoid political damage from hurting consumers. On the other: conservatives demanding a major weakening of the Affordable Care Act as the price for returning the money."

However, Stephanie Armour reports for The Wall Street Journal, "Trump has privately told at least one lawmaker that the payments may continue if a bipartisan deal is reached on health care, according to people familiar with the matter on Capitol Hill and in the health-care industry." The next distribution of the subsidies was set for around Oct. 20, and the Department for Health and Human Services said they "will be discontinued immediately." Armour notes, "The administration is scheduled to update the court on the status of the case on Oct. 30."

Amy Goldstein writes for The Washington Post that "Trump’s action so close to the fifth year’s sign-up period is sowing widespread confusion among consumers, according to leaders of insurance exchanges and ­enrollment-assistance organizations around the country. Along with other steps the White House has taken since late summer to undercut the ACA marketplaces, they predict this latest move is almost certain to suppress the number of Americans insured under the law next year."

Insurance companies are allowed to withdraw from the government exchanges if the subsidies stop. "So far, no insurers have said they would defect, but concerns remain acute," Goldstein reports. "As the number of companies selling ACA coverage has dwindled in the past two years, an increasing number of the nation’s counties have found themselves with just one participating insurer."

Anthem counties are in pink; CareSource counties are in blue
That is the case in every Kentucky county; about half will have plans from Anthem Blue Cross Blue Shield and half will have plans from CareSource. It is unknown whether those companies factored in their premiums the possibility that Trump would end the subsidies, which he had been threatening to do for months. But they appear to have played it safe; collectively, Anthem's rates will average 41 percent higher than last year, and CareSource's will be 56 percent higher.

The subsidies help reduce deductibles and other out-of-pocket expenses to people with incomes up to 250 percent of the poverty line, about $30,000 for an individual and $61,000 for a family of four.

Friday, October 13, 2017

State says number of Kentuckians getting disability benefits has exploded since 1980; rates are highest in Eastern Kentucky

By Melissa Patrick and Al Cross
Kentucky Health News

The number of Kentucky adults and children receiving disability benefits has increased in "staggering proportions," since 1980, and the Social Security disability system needs "radical reform, says a report from the state Disability Determination Services agency.

The report says that from 1980 to 2015, while Kentucky’s population grew by 21 percent, its combined disability enrollment grew by 249 percent. In the same 35 years, the national increase was 211 percent, so Kentucky's rolls were growing faster than the nation's.

By 2015, the report says, 11.2 percent of Kentuckians were receiving some form of disability benefit payment, higher than any state but West Virginia. It has held second place since the ranking were compiled, the report says.

Disability is prevalent in Central Appalachia. Twelve adjoining Eastern Kentucky counties had the state's top shares of the population receiving disability benefits in 2015, the report says: Wolfe, 24.9 percent; Owsley, 24.6; Breathitt, 23.8; Clay, 22.9; Magoffin, 22.3; Floyd, 21; Lee, 20.2; Leslie, 20; Martin, 19.3; Harlan, 18.9; Perry, 18.8; and Bell, 18.4 percent.

The report said that as the number of disability enrollees increased, so did prescriptions for controlled substances. Counties in the top 12 of disability and opioid use in 2015 (in alphabetical order) were Bell, Breathitt, Clay, Floyd, Lee, Leslie, Owsley, Perry and Wolfe.

Owsley County was in the top 12 for psychotropic drugs such as Xanax in 2001, 2005, 2010 and 2015, all the years surveyed for the report. Owsley and Clay counties were in the Top 12 for disability and opioids per person in 2001, 2005 and 2010.

Opioid prescriptions among those receiving disability payments rose from 48 doses per person in 2000 to 147 doses in 2015, an increase of 210 percent. Nationally, the use of opioids increased due to a greater emphasis on the treatment of pain and aggressive marketing by opioid manufacturers, especially in Central Appalachia, which ranks high in the share of the population on disability.

Central Appalachia has a relatively large percentage of workers who did not graduate from high school, worked in manual labor, and when injured found it difficult to get other work. Most of Kentucky's disability recipients have diseases of the musculoskeletal system and connective tissue (33.4 percent) or a mental disorder (32.8 percent), the report says. Other conditions included diseases of the circulatory, nervous and respiratory systems. National figures are similar.

Most of the state's disabled children (70 percent) are enrolled for mental disorders. Those who got Supplemental Security Income benefits or were in Medicaid had a 168 percent increase in psychotropic prescriptions from 2000 to 2015, from 273 doses per person to 457 doses.

The report's main author, Bryan Hubbard, acting commissioner of the state Department for Income Support, said in a news release, “The explosive growth of benefit dependence over the past 35 years has been fueled by a multitude of factors which are completely unrelated to the mitigation or treatment of hardship borne of genuine disability.”

A 2014 Center on Budget and Policy Priorities report said the number of disabled workers collecting monthly benefits tripled from 1980 to 2013, from 2.9 million to 8.9 million. It cited four factors for most of the increase: population growth, an aging population; growth in women's labor-force participation; and later retirements. It also offers results from several other studies with similar conclusions.

Adapted chart from Kentucky Center for Economic Policy
The liberal-leaning Kentucky Center for Economic Policy replied to the state report with similar points, noting that the share of Kentuckians aged 50 to 64 has increased by half, from 13.6 percent in 1990 to 20.2 percent in 2016, and that three-fourths of Kentuckians on disability are 50 or older. Now that baby boomers are retiring, Kentucky's disability enrollment "has dropped every year since 2013."

The state report suggests another reason for the growth in disability benefits. It says the federal Social Security Administration's culture is an obstacle to change because it is motivated to protect and expand enrollment for disability benefits in order to maintain its budget. The report says SSA administrative law judges award disability benefits "at rates substantially higher" than the state's Disability Determination Services, and it gives a list of the judges and their award rates.

The report calls for "radical reform," including making it a requirement that "objective medical evidence" be used to determine eligibility; removing all "subjective non-severe conditions" from the list of eligible conditions; and allowing the judges only to correct errors by state disability determiners. The report is available in PDF, with an accompanying PowerPoint presentation.

The report has language remarkable for a government document. After identifying politicians, lawyers, judges and doctors as obstacles to change, it says "There are individuals and institutions which exploit and derive power from an ever-expanding dependency class populated by desperate but functional people. These actors promote a dependence system which often functions as an apparatus of state sponsored suicide – anesthetizing and euthanizing its victims – a disproportionate number of whom are either young, poor, or both."

The Kentucky Center for Economic Policy said in its reply, "Concerns that DI in Kentucky is being overused reflect a fundamental misunderstanding about the program. It is actually very difficult to be approved for DI — in Kentucky as well as nationally. . . . Fewer than one in four applicants for DI receive it after an initial request in Kentucky. Ultimately, after two rounds of appeals, a total of 28.3 percent of Kentucky applicants receive DI benefits, which is below the net approval rate nationally of 32.1 percent in 2015." And it called the benefits "modest," saying "The median monthly benefit for a DI recipient in Kentucky was $1,055 per month in 2016," or $12,660 a year, "barely above the poverty line."
Research shows that disability rates are higher in more rural areas, ranging from 11.7 percent in the most urban areas to 17.7 percent in the most rural counties, according to the University of Montana Research and Training Center on Disability in Rural Communities.

The report speculates that rural rates are higher because rural populations are older. The share of people 65 and older in urban areas was 13.6 percent, compared to 18 percent in the most rural counties. The center has county disability data at http://rtc.ruralinstitute.umt.edu/resources/disability-counts-data-finder/.

Thursday, October 12, 2017

Kentucky will run out of its KCHIP money in about six months; meanwhile Congress inches toward funding the program

By Melissa Patrick
Kentucky Health News

As Congress works to fund the Children's Health Insurance Program days after the Sept. 30 deadline for reauthorization passed, Kentucky officials are confident their funding will be renewed before the federal money runs out.

"Without funding reauthorization on the federal level, we have enough money to maintain CHIP services for about six months," Doug Hogan, spokesman for the Cabinet for Health and Family Services, said in an e-mail. "We fully expect federal funding to be renewed."

An estimated 11 states are expected to run out of federal CHIP money by the end of the year, and 21 more by March 2018, according to a study by the Kaiser Family Foundation. A separate foundation report shows that the federal budget for CHIP was about $14 billion in 2016 and Kentucky's federal share was around $243 million.

CHIP and its funding vary by state with some states sharing the program's expense with the federal government. Hogan said Kentucky's program, called KCHIP, is largely funded by federal dollars.

Kentucky's program covers uninsured children younger than 19 who live in families with income at or below 218 percent of the federal poverty level, $53,628 for a family of four). The program serves about 83,000 children in Kentucky and almost 9 million nationwide.

The historically bipartisan program was initially passed in 1997, renewed in 2015 and was set to be renewed on Sept. 30 -- but Congress failed to act, instead spending its time on a second attempt to repeal and replace Obamacare which fell short a few days before the Sept. 30 deadline.

Both the Senate and House have passed bills out of committee to refund CHIP, but the Senate bill doesn't specify how the program will be paid for, and the House bill includes funding offsets that involves taking money from an Obamacare prevention fund and charging seniors who make more than $500,000 a year higher Medicare premiums. These offsets were a source of contention for Democrats, and the bill passed on a party-line vote, reports the Washington Examiner.

Since, Republicans on the House committee have agreed to return to negotiations with Democrats in hopes of reaching a bipartisan agreement, Jessie Hellmann reported Oct. 10th for The Hill.

However, the chairman of the committee, Greg Walden (R-Ore.) warned in a statement that if they can't reach a deal by the end of this week, the marked up bill will be taken up by the House when they return from their recess Oct. 23.

Dr. Terry Brooks, executive director of Kentucky Youth Advocates, said in an Oct. 2 statement that while he understands the "partisan toxicity and ambiguity" around Obamacare, "kids should not pay the price for partisan politics" and called for a bipartisian effort to extend the program's funding.

“Though leaders in Washington may assert that states should shoulder this vital coverage for children, the federal government cannot expect an already strapped state budget to absorb the costs of the program,” he said. “And Washington cannot turn its back to the families counting on CHIP to ensure better health outcomes for their sons and daughters."

He added, “Senate Majority Leader Mitch McConnell has a track record of standing tall for kids. We need him to protect CHIP – and our kids – from being a casualty in the never-ending Washington D.C. health care debate. Congress must extend CHIP funding with declarative and immediate action!”

Kentucky Voices for Health sent a letter Oct. 4 to leadership of the aforementioned House and Senate committees that had more than 100 "sign-ons" urging Congress to "quickly pass a clean extension of CHIP and continue the bipartisan commitment to this successful program." The letter noted that KCHIP had contributed to the state's uninsured rate of less than 7 percent, with the rate of uninsured children falling to 3.2 percent.

No final congressional action is expected until late October at the earliest, when the House gets back from its recess.