Up to 1/3 of rural hospitals in poor financial shape, auditor finds, calling report a baseline for local decisions that could be tough

By Melissa Patrick and Al Cross
Kentucky Health News
For a video of Edelen's press conference, click here. For a cn|2 report with video, go here.

FRANKFORT, Ky. -- As many as one-third of Kentucky's rural hospitals are in poor financial shape, and the survival of some will likely depend on their willingness to adopt new business models, state Auditor Adam Edelen said Monday.

Unveiling a nine-month study, Edelen said 15 of the 44 hospitals examined were in "poor financial health," and warned, "Closure may be an unfortunate reality for some."

Rural hospitals in purple declined to make useful financial information available to the auditor's office.

The study did not include 22 of the 66 Kentucky hospitals that are located outside metropolitan areas, which declined to participate or didn't provide the type of information requested. Edelen said those hospitals are mainly privately owned. If they had been included, Kentucky Hospital Association CEO Michael Rust said, the financial picture "would be better, but I don't think they would be substantially different."

Gov. Steve Beshear said the report was "a dated snapshot" because its most recent data was from 2013, before federal health reform was fully implemented. "Conditions are no longer the same," Beshear said in a news release. "Hospitals received more than $506 million in 2014 through new Medicaid expansion payments, while seeing significant reductions in uncompensated care costs.  Those are huge changes to hospitals’ bottom lines that are not shown here."

Edelen, who was Beshear's first chief of staff, said the full effect of federal health reform isn't certain. His report noted that Kentucky hospitals have had higher-than-average penalties from Medicare for readmitting patients within 30 days, a newly implemented feature of the law. Forty of the 63 hospitals penalized were rural, and nine of the 39 in the U.S. that got the maximum penalty were in Kentucky.

"This report doesn't speak to causation" by the reform law or the state's relatively new managed-care system for Medicaid, Edelen said, it is "not a rebuke" of either, but provides "a baseline for monitoring" by policymakers at the state and local levels.

The report says that to survive, rural hospitals must adapt to new business models, such as merging with larger hospitals or hiring them as managers, forming coalitions with other rural hospitals, or finding a health-care niche that hasn't been served.

Edelen cited Rockcastle Regional Hospital, which has become a niche provider of ventilator dependent care and the coalition formed by Morehead's St. Claire Regional Medical Center and Highlands Regional Hospital in Paintsville to provide more efficient care, improve patient access and adapt to changes under the reform law.

Adaptations might be a hard pill to swallow for many rural hospitals because they call for yet more change in the rapidly changing health-care landscape of electronic health records, managed care, Medicaid expansion and full implementation of the Patient Protection and Affordable Care Act.

Edelen said adaptation is important for rural communities, for whom "the importance of rural hospitals cannot be understated. They provide health care to 45 percent of Kentuckians and in every community they serve they act as one of the larger employers, paying a significantly higher wage than the average the community experiences."

He also cited the many small hospitals that have formed relationships with larger networks to relieve the increased administrative burden associated with the three-year-old managed-care system. The report says half the hospitals studied have reported an increase in hours spent on administration.

The report suggested that the state Cabinet for Health and Family Services negotiate better contracts with managed-care organizations, partly to streamline MCO rules and paperwork to reduce the administrative burden. "We are optimistic that the current work of the cabinet to improve those contracts is going to bear real fruit," Edelen said.

The new contracts will start July 1. In an interview, cabinet Secretary Audrey Haynes sounded optimistic about them but said she couldn't give details.

Haynes has been saying since she became secretary three years ago that many hospitals must change the way they do business. She said in an interview that the readmission penalties have forced hospitals to change by providing better discharge planning, and utilizing outpatient services like home health, nursing homes and rehabilitation.

One Kentucky hospital, in Nicholas County, has closed in the last year. Haynes said the cabinet is working with Fulton County, whose hospital is scheduled to close March 31, to explore how to continue providing care at the facility, such as an emergency room or an ambulatory surgical center.

Haynes recommended in the interview that all nonprofit hospitals put audited financial records and their tax returns on their websites and adhere to open-meeting laws.

In a lengthy response, included in the report, Haynes rejected Edelen's suggestion that her cabinet regularly monitor the fiscal strength of rural hospitals. She said in the interview that would pose a conflict of interest, since the cabinet regulates the hospitals.

Edelen's analysis of hospitals' financial health was based on percentage of revenue kept as profit, number of days of cash on hand, debt financing and depreciation. It found that the financial condition of 68 percent of Kentucky’s rural hospitals scored below the national average.

Edelen's office also surveyed rural hospital administrators, held 11 public hearings and met with representatives of all five Medicaid managed-care companies. His report found that:

• Rural hospitals that were geographically well-positioned, such as Pikeville Medical Center, scored high while geographically-isolated hospitals, like those in Clinton and Wayne counties, scored low. The Clinton County Hospital is in bankruptcy to restructure debt incurred for an expansion and modernization.
• The Pikeville hospital, formerly Pikeville Methodist, was one of only three judged to be in excellent financial health. The others were critical-access hospitals in Franklin and Morganfield.
• Critical-access hospitals, which limit their beds, services and patient stays to qualify for federal reimbursement at 101 percent of cost, scored better than regular acute-care hospitals. They accounted for seven of the 14 that were above the national average and thus were rated "good."
• Fifteen hospitals were rated "fair" and 15 were rated "poor." Westlake Regional Hospital in Columbia, which is in bankruptcy, was at the bottom, far worse than the next highest, St. Joseph Mount Sterling.
• The number of health-care providers across the state – particularly in rural Kentucky – dropped significantly between 2013 and 2014. The cabinet disputed that finding, based on different measurements.

Here are the rankings (click on the image for a slightly larger version):

Researchers discuss physical activity as a way of maintaining or improving health; daily walking is still the best exercise

By Melissa Patrick
Kentucky Health News

Obesity worsens the damage that arthritis does to joints, but simply telling patients to go home and diet and exercise is not working, and health care providers must proactively monitor their patients and help them find affordable solutions to succeed. And daily walking is still the best exercise.

Those were examples of research findings discussed at the 10th annual Center for Clinical and Translational Science conference sponsored by the University of Kentucky on March 25. More than 700 researchers, students, policymakers and guests discussed research with a focus on physical activity across the lifespan.

Stephen Messier, professor and director of a biomechanics laboratory at Wake Forest University, said obesity has a significant effect on joint health, particularly osteoarthritis, which he said is quite painful. He called for closer attention to obese patients with arthritis.

He said a study found that a combination of diet and exercise over an extended period of time offers the best results for less pain and less disability. He said that a separate study found those who lost 10 percent of their body weight had the most "significant outcomes" related to function, which included walking speed.

The conference featured 31 oral presentations and 270 poster presentations, addressing a vast array of topics including physical inactivity in children, physical inactivity in chronic disease and biomedical informatics.

"The conference was designed to raise awareness of the science behind the benefits of exercise and the dangers of physical inactivity," Charlotte Petterson, professor and associate dean of research in the College of Health Sciences, who chaired this year's conference, said in a UK press release.

The keynote speaker, Duke University medicine professor William E. Kraus, encouraged walking as a proven and simple activity that can improve health and actually extend life. "Fitness always trumps fatness," he said, noting that a "culture of convenience" and conditions of built environments, such as absence of sidewalks, deter people from physical activity.

Research on fourth and fifth graders in two Clay County schools, while in the early stages of analysis, found that obesity and inactivity begins early.

Karyn Esser, professor of physiology at the UK College of Medicine, said her research was examining the circadian rhythms and physical activities of students because changes in natural circadian rhythms "can create pre-cursors to disease" in just seven days, even in healthy young people. She said her study is intended to help schools improve students' health by adjusting meal times and offering physical activities to best coincide with circadian rhythms.

The data for Esser's study was gathered through electronic devices that the 136 students wore for seven days to measure activity, heart rate and skin temperature. The students also kept a daily journal to record their activities. So far, Esser said, the data show 33 percent of the students are considered obese, their initial blood pressure measurements are on the high end of normal, and the students are less active on weekends and nights than during the school week.

Another UK study found that students who are more active during the school day do better in mathematics.

Alicia Fedewa and Heather Erwin of the College of Education said they found that increased physical activity levels "significantly improved" math scores and slightly improved reading scores of the students who got an extra 20 minutes of movement on each school day. They recommended two short 15-minute recesses per day, rather than one long one. They also said that classroom "energizers" and stability balls also help students with these behaviors.

The researchers said many studies show that students who participate in recess and physical education during the school day are more focused and less fidgety, show less listlessness, and have better overall classroom behavior. They said more controlled studies need to be conducted, but said most studies to date have found that fit kids have less anxiety and better overall well-being. Also, a regimen of consistent physical activity is best for kids with attention deficit hyperactivity disorder (ADHD).

Washington Post columnist looks at data, talks to experts and concludes Obamacare is working, at less cost than expected

The federal health-reform law "has accomplished its goal of expanding coverage — at a significantly lower cost than expected," columnist Ruth Marcus writes for The Washington Post "after talking to numerous health-care experts and examining the data."

Marcus writes up front, "There is a legitimate ideological debate about whether it is a wise use of federal power to require individuals to obtain health insurance or a wise use of federal resources to spend so much on subsidizing coverage. What’s more puzzling, and more disturbing, is the still-raging division over the real-world effect of the ACA."

She says President Obama "over-promised when he told people that, if they liked their health insurance, they could keep it; by its own terms, the law set new standards for required coverage. Certainly, some individuals, particularly younger and healthier customers, find themselves paying more; again, such winners and losers were an inevitable consequence of the individual mandate and minimum-coverage rules. Meantime, the scariest warnings — of employers rushing to drop coverage and insurance markets ensnared in death spirals of ever-rising premiums — have not come to pass.
Where the law has yet to fully deliver on its promises — and some wonder whether it will — is in the area of cost containment and quality improvement."

Marcus backs up her assessment with facts. For example, "Health-care costs and premiums for employer-sponsored insurance (the way most of us obtain coverage) have been rising at their lowest levels in years. On the exchanges, premium increases during the law’s second year mirrored that modest growth — averaging 2 percent on some mid-range plans and 4 percent on the lowest-cost ones, according to the Kaiser Family Foundation."

Woman needing lung transplant falls through cracks of health-care system, says she's treated as nothing more than a 'price tag'

Katie Prager, a 24-year-old cystic fibrosis patient from Ewing in Fleming County, needs a lung transplant, but has been denied one because she has met her lifetime maximum on Medicare, Christy Hoots reports for The Ledger Independent in Maysville.

Photo from The Ledger Independent

"They've put a price tag on my name. That's all I am to these people right now," Prager told Hoots from her hospital bed at the University of Kentucky's Chandler Medical Center.

Prager has had cystic fibrosis her entire life, but it was a diagnosis of an infection called burkholderia cepacia in 2009 that caused her lung function to rapidly decline and caused the need for a lung transplant. She was told in 2013 that the UK Center for Cystic Fibrosis does not do transplants on cystic fibrosis patients with this infection, so she was sent to the University of Cincinnati hospital, Hoots reports.

She and her husband Dalton Prager, who also has cystic fibrosis, were then sent to the University of Pittsburgh Medical Center because it is only one of two hospitals that will transplant a lung into a patient with this infection. They began evaluations in January 2013.

Dalton Prager was quickly approved and successfully received a double lung transplant in November 2013. Katie Prager wasn't approved until June 2013. While waiting for a donor lung, she was discharged to spend Christmas with her family, only to hear from the hospital that she could not return there because the Medicare maximum had been reached.

"At first, I thought I might be able to use Medicaid, but was told that it wouldn't cover my transplant due to UPMC being out of network," Katie Prager told Hoots. "After explaining to Medicaid that there are only two places in the country who would operate, due to cepacia, they still refused to work together to help me. In January 2015 I filed an appeal with Medicaid to have them reconsider. The appeal was denied."

She was recently told she would never be eligible to return to UPMC for a transplant and there was nothing else they could do for her, Hoots reports.

"They told me to basically stop wasting my time," she told Hoots. "These are people who we're trusting with our lives and they say that. Most people have no problems when they have to have medical treatments or transplants, and I'm being given the runaround. I'm not trying to be a burden on the system -- that isn't what I want. If I could work and get my own insurance, I would. All I want is a normal chance at life. I want to get my bachelor's degree, get up every day and go to work, run a 5K and have a normal life with my husband. I want to do all the things that young people in love get to do. Is that so much to ask?"

Kentucky is one of three states to get Walmart Foundation money to expand farm-to-school programs

Kentucky will use money from The Walmart Foundation to partner with the National Farm to School Network to expand efforts to get more local foods into schools.

A project called Seed Change will “jump start” programs that get local foods into schools and enhance food education for more than 1.8 million school children at 100 sites in Kentucky, Louisiana and Pennsylvania, the network said in a news release. Each site will get $5,000 grants, with applications to be accepted later this spring.

The state Department of Agriculture’s farm-to-school program connects schools with local farmers and food producers and helps students "learn to appreciate the importance of local foods and grow into well-informed consumers who demand local foods as adults," the release said. The program served an estimated 364,000 children in about 700 schools in 84 districts in the 2011-12 school year. For more information on the program, go to www.kyagr.com or contact Tina Garland at 502-382-7505 or tina.garland@ky.gov.

New health-related laws deal with heroin, dating violence, end-of-life care, prescriptions, colon-cancer and newborn screening

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The Kentucky General Assembly passed several health-related bills this session, including high-profile measures on heroin and dating violence. It did not pass many others, including one that would have a great influence on the state's health: a statewide smoking ban, which passed the House for the first time ever, but never got out of an unfavorable committee in the Senate. Here's a roundup:

Heroin: Kentucky's heroin-overdose epidemic was caused partly by a 2012 legislative crackdown on prescription painkillers, which steered users to the illegal drug. Last year's bill died because of deadlock over sentences for traffickers and needle-exchange programs for addicts, and Gov. Steve Beshear and legislators gave this year's bill top priority. It was not finally negotiated until a few hours before passage, but Beshear signed Senate Bill 192 into law less than 12 hours after it passed so that its emergency clause could put it into effect immediately.

SB 192 includes both a needle-exchange program and harsher penalties against traffickers, the main points of contention between the House and Senate, but requires local governments to approve needle exchanges and allows judges to be lenient in sentencing addicts, to help them get treatment. It allocates money for drug-treatment programs, allows increased access to Naloxone, a drug that reverses the effects of an overdose, and allows jailers to provide medically assisted treatment for inmates with opiate addiction.

Dating violence: After 10 years of lobbying and debate, the dating violence bill will allow dating partners to get interpersonal protective orders from a judge if they have been the victim of dating violence, sexual abuse or stalking. This year's bill largely dissolved social conservatives' opposition by creating a new chapter in the law for dating violence, with the same protections as the domestic-violence law. Kentucky is the last state to offer protection to dating-violence victims. House Bill 8 was sponsored by Rep. John Tilley, D-Hopkinsville, who also sponsored the House heroin bill.

Beshear has signed these bills into law:

Prescription synchronization: SB 44, sponsored by Sen. Julie Raque Adams,R -Louisville, will allow patients with multiple prescriptions, in consultation with their health-care provider and their pharmacist, to synchronize prescriptions so that they may be picked up at the same time.

Medical order scope of treatment: SB 77, sponsored by Sen. Tom Buford, R-Nicholasville. will create a medical order scope of treatment (MOST) form that specifically directs the type of treatment a patient would like to have, and how much intervention he or she would like to have, during end-of-life care.

Colorectal cancer screening: SB 61, sponsored by Sen. Ralph Alvarado, R-Winchester, will require that a fecal test to screen for colon cancer, and any follow-up colonoscopy, be considered preventive measures that health insurance is required to cover without imposing additional deductible or co-insurance cost. The governor also signed a similar measure, HB 69, sponsored by Rep. Tom Burch, D-Louisville, which contains an amendment by Sen. Julian Carroll, D-Frankfort, for a Medicaid savings study.

Newborn screenings for fatal disease: SB 75, sponsored by Sen. Alice Forgy Kerr, R-Lexington, will require all newborns to be tested for Krabbe disease, a neurological disorder that destroys the protective coating of nerve and brain cells and is fatal once symptoms occur.

Spina bifida: SB 159, sponsored by Adams, will require medical providers to supply written, up-to-date, accurate information to parents when their unborn child is diagnosed with spina bifida so they can make informed decisions on treatment.

Emergency care for strokes: SB 10, sponsored by Sens. Stan Humphries, R-Cadiz, and David Givens, R-Greensburg, requires that local emergency services have access to a list of stroke-ready hospitals, comprehensive stroke centers and primary stroke centers in Kentucky. Emergency medical providers will set their own protocols for assessment, treatment and transport of stroke patients.

Alcohol and drug counselors: HB 92, sponsored by Rep. Leslie Combs, D-Pikeville, creates an enhanced licensing program to recognize three levels of certified alcohol and drug counselors, with different levels of education. The goal is to increase the number of counselors in the state.

UK cancer research center: HB 298, sponsored by Rep. Rick Rand, D-Bedford, revises the state budget to authorize $132.5 million, half of the cost, for a new medical research center at the University of Kentucky. The university says it will raise money to cover the other half.

These health bills awaited the governor's signature Monday morning:

Physician assistants: HB 258, sponsored by Rep. Denver Butler, D-Louisville, to allow physicians to supervise up to four physicians at the same time, rather than two.

In-home care: HB 144, sponsored by Burch, to establish a 60-day, hospital-to-home transition program through an approval waiver from the Department for Medicaid Services.

Pharmacist-practitioner collaboration: HB 377, sponsored by Rep. Dean Schamore, D-Hardinsburg, to allow collaboration between pharmacist and practitioners to manage patients' drug-related health needs.

Tax refund donations: SB 82, sponsored by Sen. Max Wise, R-Campbellsville, to put an income tax check-off box on tax forms to allow people the option of donating a portion of their tax refund to support pediatric cancer research, rape crisis centers or the Special Olympics.

Health related bills that were left hanging:

The smoking ban, HB 145, sponsored by Rep. Susan Westrom, D-Lexington, never got a hearing in the Senate Veterans, Military Affairs and Public Protection Committee, and neither did the Senate companion bill, SB 189, sponsored by Adams.

Three bills challenged Medicaid managed-care companies. SB 120, sponsored by Alvarado, would have created a process for health-care providers to appeal the companies' decisions to the state passed the Senate, but not the House.  And the following two bills that never got out of the Senate: SB 88, also sponsored by Alvarado, which challenged the $50 "triage fees" MCOs pay for emergency-room visits that they conclude were not emergencies, and would have required them to pay contracted fees instead and SB 31, sponsored by Buford, which would limited the amount of co-payments. Also not getting House action was Alvarado's SB 6 would have created review panels for lawsuits seeking damages from health-care providers.

You can volunteer for medical research by signing up through a national registry that connects volunteers and researchers

Have you ever wondered how you could volunteer for medical research?

ResearchMatch provides this opportunity through a national registry that brings together volunteers who are interested in research, and researchers who are looking for participants for their studies, University of Kentucky President Eli Capilouto said in a letter of invitation to participate.

"Too often, studies end early because there are not enough volunteers, leaving important questions unanswered and new treatments undiscovered. But you can help make a difference," Capilouto said in the letter.

ResearchMatch is an easy-to-use, secure registry where anyone can sign up to volunteer to participate in studies. It needs both healthy participants as well as those with medical conditions to sign up. Specific medical conditions and studies can be searched for on its "About" or "Volunteer" pages. The list of current research studies at UK can be found by visiting UKclinicalresearch.com or e-mailing ukclinicalresearch@uky.edu.

Participation might involve filling out a questionnaire, maintaining a diary, taking new medications or using a new device. The choice to participate in the study is always up to the volunteer and your name can be removed at any time. The registry has more than 74,000 participants and is operated by Vanderbilt University, a partner of the UK Center for Clinical and Translational Science.  

How has the federal health-reform law changed your care?

Despite the controversy that continues to surround the Patient Protection and Affordable Act five years after its passage, it has probably changed the way your health care is delivered as it drives new models of payment, forces providers to approach care differently, and changes how health care is evaluated, Kavita Patel and Domitilla Masi report for the Brookings Institution.

Here are five ways the authors say that your health care might be different than it was five years ago because of the reform law:

Your physician might be part of a patient care team. New payment models in the ACA encourage an interdisciplinary team-based approach, which evidence shows "can lead to higher quality care and better health outcomes for patient." This approach allows the physician to spend more time diagnosing and devising a treatment plan, while the patient may spend more time interacting with non-physician staff for support care.

Prevention and wellness are more important than ever. The ACA requires health plans to cover all preventive screenings, immunizations and well visits for women at no cost, as part of the minimum benefits required in order for health-insurance plans to participate in exchanges like Kynect. The new payment models also pay physicians who work toward keeping their patients healthy, instead of just treating them when they are sick. " Since the policy took effect in September 2010 it is estimated that an additional 76 million people now receive preventive care," the authors write.

You may have better access to care on evenings and weekends. New payment models are driving this change as practices are often required to offer extended hours to decrease the overuse of emergency departments. Many offices now offer clinical advice around the clock with a clinician who has immediate access to their medical records.

Chances are your health information is being stored in an electronic health record, not a paper file. A separate law encouraged the use of EHRs, but "participation in the new ACA-promoted delivery models is practically impossible" without them. And while EHRs can be used to greatly improve patient care, not all EHRs are created equal and it will take time before patients see seamless integration and exchange between different doctors and settings in "real-time".

You can access care remotely, wherever you are. Doctors are using mobile technology and tele-health in rural and remote areas to provide more efficient care to patients. Insurance companies and employers are beginning to recognize this mode of treatment not only as a way to save money, but to also provide timely access to care, that does not involve the emergency room.

Federal dietary guidelines recommend cutting back on red and processed meat, sugar and refined grains

The Department of Agriculture and the Department of Health and Human Services have released proposed 2015 Dietary Guidelines for Americans. The guidelines, released every five years, "provide authoritative advice about consuming fewer calories, making informed food choices, and being physically active to attain and maintain a healthy weight, reduce risk of chronic disease, and promote overall health," says USDA.

It shouldn't come as a surprise that the 2015 guidelines recommend eating healthier foods, while cutting back on less healthy alternatives. "The committee basically recommended Americans take up a diet that is higher in vegetables, fruits, whole grains, low- or non-fat dairy products, seafood, legumes and nuts," Chris Clayton reports for DTN The Progressive Farmer. "We should cut back on red and processed meats and sugar-sweetened foods, drinks and refined grains. And we should be moderate in our alcohol."

Recommended cutbacks of certain foods have not gone over well with those food producers, who met this week to give feedback on the Dietary Guidelines Advisory Committee's recommendations, Clayton writes. The North American Meat Institute argued that "lean meat, poultry, red and processed meats should all be part of a healthy dietary pattern because they are nutrient-dense protein."

Shalene McNeill, a nutritionist for the National Cattlemen's Beef Association, "told the committee that its recommendation to exclude lean meat ignores decades of nutrition science," Clayton writes. McNeill said Americans should be encouraged to eat more lean meat, along with fruits, vegetables and whole grains. Grain, sugar and milk producers also expressed displeasure with the proposed rules.

Most nutritionists have embraced the proposed rules, but say the key is getting people to adopt them, Andrea McDaniels reports for The Baltimore Sun. Among those rules is limiting sugar intake to 200 or less calories, or 10 percent of total calories, per day. Currently, Americans get about 13 percent of their calories, or 268 calories, from added sugar.

"On the flip side, some foods once shunned are now accepted," McDaniels writes. "Research has found that cholesterol-high foods are no longer believed to contribute to high blood cholesterol, so people can now indulge in shrimp, eggs and other foods that were once off limits, the panel said. Rather than focus on cholesterol, people should curb saturated fat to about 8 percent of the diet."

The panel also said "up to five cups of coffee a day are fine, so long they are not flavored with lots of milk and sugar," McDaniels writes. "The panel also singled out the Mediterranean diet—rich in fish and chicken, fruits and vegetables, nuts, whole grains, olive oil and legumes—for its nutritional value."

Heroin bill finally passes and is signed into law; Naloxone program put into motion; dating-violence bill sent to Beshear

By Melissa Patrick
Kentucky Health News

The long-negotiated bill to tackle Kentucky's heroin-overdose epidemic passed in the final hours of the 2015 legislative session.

Almost immediately after the heroin bill passed the Senate, a bill to offer immediate civil protections to dating partners who are victims of dating violence was passed after being held in the chamber since February 13 -- likely because Democratic Rep. John Tilley of Hopkinsville, chair of the House Judiciary Committee, was the original sponsor of both bills.

Tilley told reporters that the passage of the two bills meant it had been a successful session.

Gov. Steve Beshear signed the heroin legislation, Senate Bill 192, into law Wednesday, March 25, less than 12 hours after it passed, so that its emergency clause could put it into effect immediately. The dating violence bill, House Bill 8, has been delivered for his signature.

"Senate Bill 192 is tough on traffickers who bring these deadly drugs into our communities, but compassionate toward those who report overdoses or who admit they need help for their addiction," Beshear said in a release. "I applaud our legislators for putting aside partisan interests for the greater good of all Kentuckians who have been affected by this devastating drug."

The bill passed the Democrat-controlled House 100-0 and the Republican-controlled Senate 34-4. Republican senators John Schickel of Union, Joe Bowen of Owensboro, Chris Girdler of Somerset and Paul Hornback of Shelbyville voted against it.

The stickiest issues were a needle-exchange program, which many senators opposed, and tough new penalties for drug traffickers, which Tilley and many House members said would not be effective. The new law allows needle-exchange programs of approved by local governments, and the tough penalties, but allows the judge to be lenient in sentencing if the defendant is an addict.

The bill also allocates money for drug treatment programs; includes a "good Samaritan" provision that allows a person to seek medical help for an overdose victim and stay with them without fear of being charged; access for addicts and their families to the drug Naloxone, a drug that reverses the effects of an overdose; and allows the Department of Corrections to provide an approved medication to inmates to prevent a relapse in their addiction.

"The bill includes provisions that are important to law enforcement and me: increasing penalties for large volume traffickers, expanding access to treatment, and getting heroin overdose reversal kits into the hands of our first responders. I know this legislation will save lives," Attorney General Jack Conway said in a news release.

Hornback argued that "forced rehab doesn't usually work," providing addicts with Naloxone and free needles simply enables them and the bill does not allow addicts any "consequences for their actions."

He said that while he knows there are people dying from heroin overdoses,"I didn't make that decision for them and I for one, and a lot of my constituents are tired of paying for people's bad decisions and that is what this (bill) does."

Tilley said in an interview after the vote that needle exchange programs are proven to work, will save taxpayers money and are absolutely necessary to "stem the tide of two tidal-waves that are headed Kentucky's way: HIV and Hepatitis C and Hepatitis B."

"The cost of treating someone with HIV is $350,000. The cost of treating someone with Hepatitis C is $85,000. The budget now had a $55 million hit just with the explosion of Hepatitis C last year. We can't afford that in Kentucky," he said. Advocates say the programs can be a gateway to treatment and rehabilitation.

Meanwhile, Conway and first lady Jane Beshear announced that funding for Naloxone kits would be made available to the hospitals in Kentucky with the highest rates of heroin overdose deaths. The kits will be provided free to every treated and discharged overdose victim at the pilot-project hospitals.

They made the announcement at the University of Louisville, which treated 588 people in 2013 for heroin overdoses, a news release said. In 2013, the latest data available, 230 of the 722 autopsied overdose deaths, or 32 percent, were caused by heroin, according to the Kentucky Office of Drug Control Policy.

Tilley and Republican Sen. Whitney Westerfield, also of Hopkinsville, "forged a friendship that allowed the two men to work out differences on a pair of high profile bills fraught with political pitfalls," Adam Beam reports for The Associated Press. "Westerfield, a former prosecutor, is running for attorney general against the son of Democratic Gov. Steve Beshear, giving Democrats all the reason in the world not to work with him."

The AP notes that Republican Sen. Chris McDaniel wrote the first draft of the heroin bill that passed the Senate in January, but it omits McDaniel's other role: candidate for lieutenant governor on a slate headed by Agriculture Commissioner James Comer. As the Senate prepared to give the final bill final passage, Republican Floor Leader Damon Thayer accused the House of not passing McDaniel's bill because of his candidacy.

Read more here: http://www.kentucky.com/2015/03/25/3767938_political-compromises-brokered.html?rh=1#storylink=cpy

County Health Rankings look familiar, but show that some counties overcame bad factors to have encouraging outcomes

The 2015 County Health Rankings for Kentucky, compiled by the University of Wisconsin Population Health Institute in collaboration with the Robert Wood Johnson Foundation, have been released. For the fourth year in a row, Oldham County ranked highest in Kentucky for health outcomes. Statistical differences among closely ranked counties are very small, so rankings are arranged in quartiles (quarters) in the maps below.

The rankings fall into two categories: factors and outcomes. Health factors, left, include the health behaviors (with factors such as adult smoking), clinical care (with factors such as the ratio of population to primary-care physicians), social and economic factors (such as the percentage of children under 18 in poverty) and physical environment (with factors such as the percentage of workforce that drives alone to work). Oldham County was followed by Boone, Woodford, Scott and Anderson counties. Clay County ranked last, preceded by Martin, Leslie, Wolfe and Knott. Generally, health factors and outcomes reflect income and education levels.

Health outcomes, right, include premature death, poor or fair health, poor physical health days, poor mental health days and low birthweight. Boone County ranked first, followed by Oldham, Shelby, Fayette and Jessamine. Owsley County ranked last, preceded by Floyd, Leslie, Clay and Perry.

Some counties, such as Morgan and Wayne, overcame their poor health factors to have better-than-average outcomes. To see the full, specific list of county rankings, click here.

Health reform law has been good for hospital finances, health-care costs, Obama administration says

U.S. hospitals have saved billions of dollars because the federal health-reform law has provided coverage for patients who were once charity cases, the Obama administration announced Monday, the fifth anniversary of the Patient Protection and Affordable Care Act.

"Hospitals also saw fewer emergency room visits, which rack up far higher costs and often leave hospitals with the tab," Sarah Ferris writes for The Hill, which covers Congress. "The government’s report, which focuses on the benefits of Medicaid expansion, is an effort to entice states that have been politically resistant to expanding the program."

Kentucky hospitals have acknowledged that the law has reduced their losses from "uncompensated care," but say other aspects of the law have created a mixed effect, depending partly on hospitals' ability to adapt. The increase in coverage has brought hospitals much more money, but they say continued problems with managed-care Medicaid have cause them financial difficulty.

From paying patients' point of view, the law appears to have reduced inflation in health-care costs, but has not achieved advocates' goal of reducing costs. A White House report said, "Since the Affordable Care Act was enacted, health care prices have risen at the slowest rate in nearly 50 years. Thanks to exceptionally slow growth in per-person costs throughout our health care system, national health expenditures grew at the slowest rate on record from 2010 through 2013."

For the White House's Kentucky-specific list of benefits of the law, click here.

Reform law 'quietly accomplishing the goals it was created to achieve,' McClatchy Newspapers reporter writes

The federal health-reform law is still controversial and still facing a legal challenge, but "is quietly accomplishing the goals it was created to achieve," Washington correspondent Tony Pugh reported for McClatchy Newspapers on the occasion of the law's fifth anniversary. (The Lexington Herald-Leader is a McClatchy paper.)

"The nation’s uninsured rate has plummeted as more Americans enroll in Medicaid or in federal and state marketplace coverage," Pugh notes. "The law’s consumer protections and insurance-benefit requirements have improved the quality of coverage for millions of people who get health insurance outside the workplace. Premiums for marketplace health insurance have largely been reasonable and have increased only moderately thus far. Long-term cost estimates for providing coverage under the law have been falling."

Howver, Pugh writes, "The law may never overcome the bitter politics that surrounded its enactment and that partly define its legacy. Long viewed as a government overreach, the health-care law has been problematic for those who want the private insurance market to dictate who gets health insurance and what it should cost. . . . Moreover, the law’s requirement that most Americans have health insurance is seen as an infringement on individual freedom. The Supreme Court ruled in June 2012 that the so-called individual mandate didn’t violate the Constitution."

The White House issued a state-specific list of the law's benefits. For Kentucky's, click here.

Obama says health-reform law working better than expected

President Obama made this statement on the fifth anniversary of the Patient Protection and Affordable Care Act:

On the five-year anniversary of the Affordable Care Act, one thing couldn’t be clearer:  This law is working, and in many ways, it’s working even better than anticipated.

After five years of the Affordable Care Act, more than 16 million uninsured Americans have gained the security of health insurance – an achievement that has cut the ranks of the uninsured by nearly one third.  These aren’t just numbers.  Because of this law, there are parents who can finally afford to take their kids to the doctor.  There are families who no longer risk losing their home or savings just because someone gets sick.  There are young people free to pursue their dreams and start their own business without worrying about losing access to healthcare.  There are Americans who, without this law, would not be alive today.

For Americans who already had insurance before this law was passed, the Affordable Care Act has meant new savings and new protections.  Today, tens of millions of Americans with pre-existing conditions are no longer at risk of being denied coverage.  Women no longer have to worry about being charged more just for being women.  Millions of young people have been able to stay on their parents’ plan until they turn 26.  More than 9 million seniors and people with disabilities have saved an average of $1,600 per person on their prescription medicine, over $15 billion in all since the Affordable Care Act became law.  More than 70 million Americans have gained access to preventive care, including contraceptive services, with no additional out-of-pocket costs.  And the law has helped improve the quality of health care: it’s a major reason we saw 50,000 fewer preventable patient deaths in hospitals over the last three years of data. 

The cynics said this law would kill jobs and cripple our economy.  Despite the fact that our businesses have created nearly 12 million new jobs since this law was passed, some still insist it’s a threat.  But a growing body of evidence – actual facts – shows that the Affordable Care Act is good for our economy.  In stark contrast to predictions that this law would cause premiums to skyrocket, last year the growth in health care premium costs for businesses matched its lowest level on record.  If premiums had kept growing over the last four years at the rate they had in the last decade, the average family premium would be $1,800 higher than it is today.  That’s $1,800 that stays in your pocket or doesn’t come out of your paycheck.  And in part because health care prices have grown at their slowest rate in nearly 50 years since this law was passed, we’ve been able to cut our deficits by two-thirds.  Health care costs that have long been the biggest factor driving our projected long-term up deficits up are now the single biggest factor driving those deficits down. 

The Affordable Care Act has been the subject of more scrutiny, more rumor, more attempts to dismantle and undermine it than just about any law in recent history.  But five years later, it is succeeding – in fact, it’s working better than even many of its supporters expected.  It’s time to embrace reality.  Instead of trying yet again to repeal the Affordable Care Act and allowing special interests to write their own rules, we should work together to keep improving our healthcare system for everybody.  Instead of kicking millions off their insurance and doubling the number of uninsured Americans, as the House Republican budget would do, we should work together to make sure every American has a chance to get covered.

Five years ago, we declared that in America, quality, affordable health care is not a privilege, it is a right.  And I’ll never stop working to protect that right for those who already have it, and extend it to those who don’t, so that all of us can experience the blessings of life, liberty, and the pursuit of happiness in this country we love.  

As tax deadline nears, most uninsured appear likely to choose penalty; some with coverage are having to refund part of subsidy

Kentucky Health News

Most people facing a tax penalty for not having health insurance appear likely to pay it instead of taking advantage of a special opportunity to but coverage and minimize the penalty.

"Major tax-preparation firms say many customers are paying the penalty and not getting health insurance," reports Stephanie Armour of The Wall Street Journal. "Research also suggests that many people who lack health insurance will pay the penalty and not get covered this year."

Many polls have found that many if not most people without health insurance are unaware that they are subject to a tax penalty under the federal health-reform law. That percentage appears to be declining as they prepare their income-tax returns, but a poll taken in late February found that when told of the penalty, only 12 percent of the uninsured said they would get coverage.

For many people, the choice is simply financial, since coverage for them would be more expensive than the penalty -- 1 percent of their income, or $95 per adult or $47.50 per child, whichever is larger. Others say they don't need coverage, and some object to the penalty or the law altogether.

The penalty will increase to 2 percent of income and $325 per adult or $167.50 per child for the 2015 tax year, so if you are uninsured and don't qualify for Medicaid or one of the law's exemptions, the end of the special enrollment period, April 30, is the last chance to avoid that penalty.

"In late February, H & R Block reported that its uninsured clients had paid an average penalty of $172," reports Abby Goodnough of The New York Times. "The money comes out of refunds, while people who do not get refunds are required to pay the Internal Revenue Service by April 15."

Some people who have coverage "might find another unpleasant surprise: As many as half the nearly 7 million Americans who got subsidies to offset their premiums may have to refund money to the government, according to an estimate by H & R Block," the Journal reports. "The subsidies are based on consumers’ own projections of their 2014 income, but some estimated incorrectly and received overly generous credits. Those people will see smaller-than-expected refunds or could owe the government money."

"H & R Block also found that as of Feb. 24, just over half of its clients with subsidized marketplace coverage had to repay a portion of their subsidy because their 2014 income turned out to be higher than what they estimated when they applied for coverage," the Times reports. "The process includes "new forms that even seasoned preparers are finding confusing."

The Obama administration announced last month that 800,000 people with insurance bought under the reform law had received incorrect information needed for their tax returns. About 10 percent of them have still not received corrected forms, it announced Friday. "The administration said people who have not received the corrected forms do not have to wait to file their taxes and will not have to pay any additional tax due to the effort," The Hill reports.

The Wall Street Journal reports, "Consumers who already filed their tax returns using the incorrect forms provided though state or federal exchanges won’t be required to file amended forms, and the Internal Revenue Service won’t assess additional taxes, said Mark Mazur, the Treasury Department’s assistant secretary for tax policy."

KET to focus attention on cancer with Ken Burns series March 30-April 1, live call-in program on night of April 1

Kentucky Health News

KET will show a three-night series, "Cancer: The Emperor of All Maladies," by Ken Burns, an in-depth look at the history of cancer, patients' stories and the "latest scientific breakthroughs that may have, at last, brought researchers within sight of developing lasting cancer cures," the network says in a news release.

The series, which will air March 30, 31 and April 1 at 9 p.m. ET, is based on the Pulitzer Prize-winning book The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee.

KET will air companion programs to this series that will focus on Kentuckians.

Bill Goodman will host Dr. Mark Evers, director of the Markey Cancer Center at the University of Kentucky, on "One to One" March 29 at 1 p.m. ET to discuss the latest news in cancer care and research. This show will also air on KET2 March 31 at 7:30 p.m. ET.

On April 1 at 8 p.m., Renee Shaw will host a live call-in program, "Answers for Cancer," as part of KET's "Health Three60" series. This show will offer viewers a chance to ask questions about cancer screening, treatment and recovery resources in Kentucky.

A recording of the program will air on KETKY April 6 at 9 a.m., April 10 at 11 a.m., April 11 at 4 a.m. and April 13 at 2 a.m. (all times ET).

Viewers can submit questions to the original program via Twitter at @HealthKET, by email at healthnews@ket.org, or by phone at 800-753-6237.

Panelists on the program include Donald Miller, director of the James Graham Brown Cancer Center at the University of Louisville; Patrick Williams, medical director at Norton Cancer Institute; Timothy Mullet, lung cancer specialist with UK HealthCare, who is himself a cancer survivor; and Fran Feltner, director of the UK Center for Excellence in Rural Health.

This show will also offer a pre-taped segment that spotlights cancer screening outreach efforts in Kentucky that target high risk populations.

Authors of The Great Diabetes Epidemic will talk on KET about its causes, myths, complications, treatment and prevention

Kentucky Health News

The message that the authors of The Great Diabetes Epidemic: A Manifesto for Control and Prevention want readers to take from their book is that "diabetes is a serious, but preventable disease, if proper early interventions are implemented through a community-based, public health approach," KET says in a press release.

Authors Dr. Gilbert Friedell and J. Isaac Joyner will discuss this message with host Renee Shaw, and look at the root causes of the high number of diabetes cases in the U.S. and what needs to be done about it, on "Connections with Renee Shaw" on KET2 Friday, March 27 at 5 p.m. ET and on KET Sunday, March 29 at 1:30 p.m. ET.

Other topics discussed include common misconceptions and barriers to treatment, belief systems around diabetes that aren't based on fact, and the significant health ramifications of the disease, including complications such as blindness, amputations and renal failure.

"In Kentucky alone, for example, there are 72,000 diabetes-related cases of blindness and visual impairment diagnosed each year – roughly 200 per day," KET notes.

Health reform law drives a trend to include lifestyle changes in a patient's health care plan, alongside traditional medicine

Lifestyle changes can play a huge role in treating and warding off many health conditions and thanks to the Patient Protection and Affordable Care Act there is now a shift to include helping people make these changes part of their health care plan, Laura Ungar reports for The Courier-Journal and USA Today.

In the first of an occasional series called "HealthVoices" that focuses on "areas where policy, public health and people intersect," Ungar tells the story of Kevin French, who self-describes himself as "the quintessential unhealthy Kentuckian" and how lifestyle changes have made a difference in his health.

French tells Ungar that with the help of medical professionals and The KentuckyOne Healthy Lifestyle Center in Louisville he has "learned how to eat well, handle stress, exercise and "basically change everything."

"My medicine usage has declined somewhat. I'm still on medicines but not the dramatic type like I was. Some of them's been cut in half," French told Ungar. "Several costs of medicines have declined dramatically."

The center provides "medically supervised exercise, nutrition counseling, stress management and classes in disciplines such as yoga" and is the third such facility the medical system has opened in Louisville, Ungar writes.

Experts say that the ACA is driving this "colossal shift" in health care away from the "traditional reliance on pills and procedures by patients as well as the American medical system," Ungar writes, but she also notes that the patient must also make a commitment to these lifestyle changes if it is to work, as French has.

A cardiologist at the center, Paul Rogers, told Ungar about the importance of lifestyle changes, especially exercise. in warding off cardiovascular disease, one of the state's biggest killers.

"Compared to even the best medical therapy, we can decrease heart attacks, strokes and deaths by between 35 and 45 percent by changing lifestyle. The thing I see that holds people back most probably is effort and fear," Rogers told Ungar. "The recommendations these days are 30 minutes of…aerobic activity six times a week. I think if people started devoting themselves to that, that would change the health of our state dramatically."

At roundtable on food and agriculture, Prince Charles says we need to reconnect with the food system and nature, keep stock

Prince Charles "called for urgent restructuring of local and global economies to save humanity from itself" in a whirlwind visit to Louisville on Friday, James Bruggers reports for The Courier-Journal.

In addition to a speech at the Cathedral of the Assumption, the heir to the British throne briefly participated in a roundtable on health and the environment and a similar gathering about food and agriculture, at which he said people need to become "intimately acquainted again with the food system and nature," as The Courier-Journal put it.

"I am very keen on connecting people to school gardens," he said, "and encouraging them to keep their own chickens and the occasional pig." Here's The C-J's raw video from the roundtable:

Earth can't afford to keep supporting our consumerist society as it now exists, Prince Charles tells Louisville audience

Kentucky Health News

Transcript of The Prince of Wales’s speech at the Cathedral of the Assumption, Louisville, following an introduction by Wendell Berry (subheads added)

Ladies and gentlemen, it has been an immense pleasure to spend our last day in the United States here in Louisville, guided by a very special lady. Christy Brown, if I may say so, is one of the most remarkable people I have come across; a true force of nature, with an unbounded enthusiasm to bring people together across a whole range of important issues, and with the determined tenacity to make things happen. I know from my own experience, it is very hard to say "no" to Christy Brown! It was she who asked me to articulate the principles of harmony which I have long believed to lie at the heart of how we respond to the immense challenges and dangers facing humanity. So I can only hope you are all prepared to put up with such articulation.

I must say, it is also very special to have been introduced by such a great advocate of harmony, Wendell Berry, who I am incredibly touched said those wonderful words about me. He is a very special son of Kentucky. I only wish I had time to visit his farm. I will now embarrass him by telling you that he has long been a hero of mine. I remember him once describing his farm here in Kentucky. Half of it, he said, sits at the top of a hill and the other half at the bottom, which, as he put it, "is what you call a learning situation…"

Now, to return to Christy's request: In the 1960’s, as I remember so well, a frenzy of change swept the world in the wave of post-war “Modernism.” There was an eagerness to embark upon a new age of radical experimentation in every area of human experience which caused many traditional ideas to be discarded in a fit of uncontrollable enthusiasm – ideas that will always be of timeless value for every generation confronting the actual realities of life on this Earth. I remember it only too well – and even as a teenager I felt deeply about what seemed to me a dangerously short-sighted approach, whether in terms of the built or natural environment, agriculture, healthcare or education. In all cases we were losing something of vital importance – we were disconnecting ourselves from the wealth of traditional knowledge that had guided countless generations to understand the significance of Nature’s processes and cyclical economy. It always seemed to me that in this period of change some subtle balance was being tragically lost, without which we would find ourselves in an increasingly difficult and exposed position. As, indeed, we have.

I have been trying to point out ever since where I feel the balance needs righting and where some of the discarded, but timeless principles of operating need to be reintroduced in order to create a more integrated approach. It has turned out to be a peculiarly hazardous pastime. But I have come to the inescapable conclusion that the legacy of Modernism in our so-called post-Modern age has brought us to a crucial moment in history; prompting a lot of uncomfortable questions.

The first question I want to ask is how we have landed ourselves and the rest of the world in the mess that it now struggles to overcome? We have more than enough scientific evidence that proves this to be so. But what is it that drives us on to exacerbate the problems? Why do we tip the balance of the Earth’s delicate systems with yet more destruction, even though we know in our heart of hearts that in doing so we will most likely risk bringing everything down around us? In the thirty years or so that I have been attempting to understand and address the many related problems, I have tried to ask myself what it is in our general attitude to the world that is ultimately at fault? In doing so, of course, it must have appeared as though I was just flitting from one subject to another – from agriculture to architecture, from education to healthcare – but I was merely trying to point out where the imbalance was most acute; where the essential unity of things, as reflected in nature, was being dangerously fragmented and deconstructed.

The harmonious system of nature is collapsing

The question that should surely keep us all awake at nights is what happens if you go on deconstructing? I fear the answer is all too plain. We summon up more and more chaos. I have also spent a long time wondering that if we could identify the key fault, would it be possible to fix it? And if we could, what would that “fix” amount to in practical as well as philosophical terms? What worries me is that at the moment there is not a lot of attention given to the way we perceive the world. We take our mechanistic view of it for granted and believe that the language of scientific empiricism which so dominates our discussion is the only form of language we need to guide us. So let’s be clear – whereas the empirical view of the world makes observational deductions about the laws of nature, the philosophical deals with the meaning of things; and the religious concerns itself with the sacred presence in things. They each have a role to play.

The way in which empirical enquiry has developed to this position of dominance since the Enlightenment has certainly enabled us to improve the material realm of the human condition. But let us also recognize that this progress was only possible because of an earlier and crucial shift which took us away from a traditional sense of participation in nature to the claim of mastery and exploitation over the natural order that has reaped such a troubling and bitter harvest. That earlier shift, away from seeing ourselves within nature to us standing apart from it, gradually undermined what I have always felt, deep down, to be the true situation – that if we wish to maintain our civilizations, then we must look after the Earth and actively maintain its many intricate states of balance so that it achieves the necessary, active state of harmony which is the prerequisite for the health of everything in creation. In other words, that which sustains us must also itself be sustained.

But we are not keeping to our side of the bargain and, consequently, the sustainability of the entire harmonious system is collapsing – in failing the Earth we are failing humanity. We are standing at a moment of substantial transition where we face the dual challenges of a world view and an economic system that seem to have enormous shortcomings, together with an environmental crisis – including that of climate change – which threatens to engulf us all.

Of course, we have achieved extraordinary prosperity since the advent of the Industrial Revolution. People live longer, have access to universal education, better healthcare and the promise of pensions. We also have more leisure time; opportunities to travel – the list is endless. But on the debit side, we in the industrialized world have increased our consumption of the Earth’s resources in the last thirty years to such an extent that, as a result, our collective demands on nature’s capacity for renewal are being exceeded annually by some 25 per cent.

Back in the 1950’s and right up to the 1990’s it seemed credible to argue that the human will was the master of creation; that the only acceptable way of thinking was a mechanistic way of thinking; that the Earth’s natural resources were just that – resources – to be plundered because they were there for our use, without limit. But for all its achievements, our consumerist society comes at an enormous cost to the Earth and we must face up to the fact that the Earth cannot afford to support it.

Just as our banking sector has been struggling with its debts – and paradoxically also facing calls for a return to so-called “old-fashioned,” traditional banking – so nature’s life-support systems are failing to cope with the debts we have built up there too. If we don’t face up to this, then nature, the biggest bank of all, could go bust. And no amount of quantitative easing will revive it. It seems to me a self-evident truth that we cannot have any form of capitalism without capital. But we must remember that the ultimate source of all economic capital is nature’s capital. Our ability to adapt to the effects of climate change, and then perhaps even to reduce those effects, depends upon us adapting our pursuit of “unlimited” economic growth to that of “sustainable” economic growth. And that depends upon basing our approach on the fundamental resilience of our ecosystems. Ecosystem resilience leads to economic resilience. If we carry on destroying our marine and forest ecosystems as we are doing, then we will rob them of their natural resilience and so end up destroying our own.

We are not separate from nature

No matter how sophisticated our technology has become, the simple fact is that we are not separate from nature – like everything else, we are nature. The more you understand this fact the more you see how our mechanistic way of thinking causes such confusion. Modern agri-industry, for instance, may have made enormous strides to feed the burgeoning world’s population, but at a huge and unsustainable cost to ecosystems, through massive use of artificial fertilizers, herbicides, pesticides and water. It is a reductive approach to one issue that is patently not durable because it sustains nothing but its own decline, solving one problem by creating countless others.

This, of course, is not the way nature operates. In nature the entire system is a complex unfolding of inter-dependent, multi-faceted relationships and to understand them, we have to use “joined-up” thinking. The ancient Greek word for the process of joining things up was “harmonia.” So, “joined-up thinking” seeks to create harmony, which is a very specific state of affairs. In fact, it is the very prerequisite of health and well-being. Our bodies have to be in harmony if they are to be healthy, just as an entire ecosystem has to be. This is the way nature operates. Natural sciences like microbiology and botany tell us very clearly that every kind of organism, be it big or microscopic, is a complex system of interrelated and interdependent parts – which makes each organism a microcosm of its local environment; the very essence of it, in fact. The sum of these parts builds and maintains a coherence – an active, harmonic unity – with no waste. No one part operates either in isolation or beyond the limits set by the whole.

Facing the future, therefore, requires a shift from a reductive, mechanistic approach to one that is more balanced and integrated with nature’s complexity – one that recognizes not just the build-up of financial capital, but the equal importance of what we already have – environmental capital and, crucially, what I might best call “community capital.” That is, the networks of people and organizations, the post offices and bars, the churches and community halls, the mosques, temples and bazaars – the wealth that holds our communities together; that enriches people’s lives through mutual support, love, loyalty and identity.

Just as we have no way of accounting for the loss of the natural world, contemporary economics has no way of accounting for the loss of this community capital. This is why we need to ask ourselves whether the present form of globalization is entirely appropriate, given the circumstances confronting us. There are, clearly, benefits, but we need to ask whether it requires adaptation so that it also enables, as it were, globalization from the bottom up. This, after all, is the way nature operates! At the moment we operate under a form of globalization that tends to render down all the rich diversity of a culture into a uniform, homogenized mono-culture. This is where the Modernist paradigm needs to be called into question before the damage being done is irretrievable. …

One of the chief architects of our present economic model was Adam Smith. Interestingly, he was another who recognized that, although individual freedom is rooted in our impulse for self-reliance, it must be balanced by the limits imposed by natural law. As he prepared his book, The Theory of Moral Sentiments, he moved away from the notion that we are born with a moral sense and preferred the principle of there being a sympathy in all things. It is this sympathy that binds communities together. But there is little chance of such sympathy if what people need is provided through commercial structures that place an ever greater distance between the supplier and the consumer, because economies of scale can destroy the economics of localness. It has become, again, a purely mechanical process with no room for the complexity and multi-faceted dimensions of a proper local relationship between a community and the suppliers that serve it.

A balance between the market and society

Once again, there has to be a balance between the market on the one hand and society on the other, otherwise real problems occur. … This is why city-level policy to encourage healthy local food systems could scarcely be more important. It is a way to ensure a harmonious relationship between the city and its hinterland, fostering greater understanding and respect for the services that the rural environment and economy provide. It is also a means by which a circular economy can be generated where wastes become resources rather than pollution.

So, with that in mind, how could we better empower all sorts of communities to create a much more participative economic model that safeguards their identity, cohesion and diversity – one that makes a clear distinction between the maintenance of Nature’s capital reserves and the income it produces? That is the challenge we face, it seems to me – to see nature’s capital and her processes as the very basis of a new form of economics and to engage communities at the grass roots to put those processes first. If we can do that, then we have an approach that acts locally by thinking globally, just as nature does – all parts operating locally to establish the coherence of the whole.

Here in Louisville, for instance, I met with representatives of your major food and drink manufacturers, and also spent time with farmers and food producers at what, I would suggest, is a very significant idea – the creation of the Food Hub and the development of the area around that proposed site. Re-localizing your food systems and encouraging the many small and medium-sized farms that surround your city to consider how best to offer locally produced food would make a tremendous difference to the long term sustainability of your economy, especially if real attention was paid to the health of the soil. A long time ago it was President [Franklin] Roosevelt who gave a very prescient warning when he said - "a nation that destroys its soils destroys itself." So, of central importance will be how to reconcile our urban and rural development. The actions of leading cities like Louisville can provide a demonstration of what can be done that is of value not only to the United States, but also globally.

Likewise, as far as human health is concerned, I was alarmed to hear from your leading cardiologist here, Dr. Bhatnagar, just how directly the high rates of air pollution you struggle with are related to the high levels of cardiovascular disease. If you recognize that the quality of the air is not just an "environmental" issue, but a very serious economic issue, then you can see that the health of people directly affects the health of an economy. So perhaps, at the end of the day, it might be cheaper to join up the dots and put paid to the pollution, rather than pursue the more expensive option of encouraging people to take yet more pills to help their hearts?

So, having spent the day here in Louisville, I can only offer my warmest congratulations not only for what you have already achieved, but also what you are striving for in the future – a model of truly integrated and holistic thinking on a city scale and a beacon of inspiration for others to learn from – for instance, your work in helping build communities such as at the African American Heritage Centre, the boldness of the vision for the Food Hub project (why wouldn't we all want to shorten the links between consumer and producer?); the remarkable potential of a new discussion between the health insurance companies and your major food companies who, of course, would love to become more sustainable if only the financial climate allowed them.

Could this, then, be part of the solution to the problems we face? Could it be one that might give us hope, for we do still have within our societies and within our existing technologies the solutions that will enable us to transcend our current predicament. All we lack, perhaps, is the will to establish a more entire and connected perspective. There are many examples where communities have replaced the short-term impulse with the long-term plan. But part of that strategy – to my mind at least at the heart of it – is the need for a new public and private-sector partnership which includes NGO [non-governmental organizations] and community participation. It seems to me that for this to work we need to ensure that community and environmental capital is indeed put alongside the requirements of financial capital and that we also develop transparent means to measure the social and environmental impact of our actions.

We certainly need to refine our ability to measure what we do so that we become more aware of our responsibility. This validates the need for “accounting for sustainability,” which has since become known elsewhere as true-cost accounting – a method by which businesses can take proper account of the cost to the Earth of their products and services, and which I initiated and developed 11 years ago. It is encouraging that this approach is being tested by a range of companies, government departments and agencies, and I hope that it can be adopted more generally so that well-being and sustainability can be measured, rather than merely growth in consumption.

We also need, dare I say it, new forms of international collaboration to value ecosystem services. For instance, the world must recognize the absolutely vital utility that the rainforests provide by generating a real income for rainforest countries – where, incidentally, some 1.4 billion of the poorest people on Earth rely in some way on the rainforests for their livelihoods – an income which can be used to finance an integrated, low-carbon development model. Paradoxically, the answer to deforestation lies not solely or even mainly in the forestry sector, but rather in the agricultural and energy sectors.

It is also increasingly possible to enhance efficiency and economic rates of return by linking different sectors together in what are called “virtuous circles.” You can see this in the relationship between the waste, energy and water sectors where the waste product of one process becomes the raw material of another, thereby mimicking nature’s cyclical process of waste-free recycling.

Alternatives need to become mainstream

The trouble is, at the moment, so many of these brilliant ideas sit on the fringes of our economy. They are seen as “alternatives” when they need to become mainstream. But for this to happen and for such alternatives to be effective, it will require a system of long-term consistent and coherent financial incentives and disincentives; otherwise, how else will we achieve the urgent response we need to rectify the situation we face?

Another example of an alternative that needs to become mainstream, and which would enhance both community and environmental capital, lies in the way we plan, design and build our settlements. I have talked long and hard about this for what seems rather a long time – and look what it’s done to me! – but it is yet another case where a rediscovery of so-called “old fashioned,” traditional virtues can lead to the development of sustainable urbanism. This approach emphasizes the integration of mixed-use buildings and the use of local materials to create local identity which, when combined with cutting-edge developments in building technology, can enhance a sense of place and real community.

Our need for these solutions is going to grow exponentially as our global population rises and our ecological and economic crises deepen. Is this not a rationale for investing massively in these new and more integrated approaches which, thereby, could help to create the kind of “virtuous circles” based on environmental and community capital that I have mentioned this evening? Such investment would also, I can’t help thinking, have the added benefit of creating many new jobs.

But are we prepared to take such a step? As Mahatma Gandhi pointed out, “The difference between what we do and what we are capable of doing would suffice to solve most of the world’s problems.” The starting point is to see things differently from the current, dominant world view which in so many ways is no longer relevant to the situation in which we find ourselves. The worst course would be to continue with “business as usual” as this will only compound the problem. We must see that we are part of the natural order rather than isolated from it; to see that nature operates according to an organic “grammar” of harmony and which is infused with an awareness of its own being, making it anchored by consciousness. It is an interconnected, interdependent function of creation with harmony existing between all things.

We are, ladies and gentlemen, at an historic moment – because we face a future where there is a real prospect that if we fail the Earth, we fail humanity. And I don't know about all of you but, as a grandfather, I have no intention of failing my, or anyone else's, grandchildren.

As part of Louisville visit, Prince Charles attends roundtable on health and the environment with health and environmental leaders

Press pool report by Al Cross, Kentucky Health News

His Royal Highness the Prince of Wales arrived at the foot of the Big Four Bridge, an old railroad bridge recently converted into a pedestrian bridge, at 3:07 p.m. He was accompanied by Louisville Mayor Greg Fischer and was greeted by U.S. Rep. John Yarmuth, D-Louisville. They ascended a stairway leading to the pedestrian ramp and had a discussion on the ramp. Your pool could hear only snatches of conversation, but it was clear that Fischer and Yarmuth were describing the bridge project, which links Louisville to Jeffersonville, Ind.

Dr. Elliott Antman, in sunglasses, speaks as Prince Charles and other participants listen

The group descended the ramp and entered a plastic-and-canvas tent, joining a health-and-environment roundtable that had been in progress for about an hour. The pool was present for introductory remarks by the mayor and by Dr. Elliott Antman, president of the American Heart Association, but there was no amplification and the pool was kept at such a distance that he could not be heard clearly, and we were shuffled out after just a few minutes. Through the opening and the clear plastic we could see that HRH was animatedly engaged in conversation with the participants.

Yarmuth said afterward that the conversation was “about how the health care system by itself, the medical system, is not the thing we should be concerned about in trying to be concerned about the general health and well-being of society,” but rather how to prevent people from entering that system, “and there are so many entities that have role” in doing that.

Gordon Garner, former director of the Metropolitan Sewer District and president of the Kentucky Waterways Alliance, said the broad message of the meeting was “the linkage to both the built and natural environment” when it comes to health. “The big message would be … the overwhelming need we have as a society to raise our level of stewardship .. that public awareness is way, way behind what the needs are. We’ve got to develop some kind of stewardship commitment that we currently don’t have.”

According to an email from Chuck Lambert of Humana Inc. to the participants, a copy of which your pool reporter obtained, following are the invited participants. It could not be confirmed whether all on the list were actually at the roundtable.

INVITEES to roundtable (other than Antman, mentioned above):

Dr. Aruni Bhatnagar, Ph.D., Institute of Molecular Cardiology, University of Louisville

Lt. Gen. Patricia Horoho, 43^rd U.S. Army Surgeon General

Meredith Barrett, vice president of science and research, Propeller Health

Dr. Alonzo Plough, vice president of research, evaluation and learning and chief science officer, Robert Wood Johnson Foundation

Dr. Sharmila Makhija, chair of ob/gyn and women’s health, Albert Einstein College of Medicine, The Bronx, N.Y. (formerly at U of L)

Tom FitzGerald, director, Kentucky Resources Council (Kentucky’s leading environmental lobbyist)

Dr. Ted Smith, executive director, Institute for Healthy Air, Water and Soil; and chief of civic innovation, Metro Louisville government

Peter Crane, dean, Yale School of Forestry and Environmental Studies

Mary Gwen wheeler, executive director, 55,000 Degrees (program aimed at expanding number of college graduates in Louisville)

Dr. James Sublett, president, American College of Allergy, Asthma and Immunology

Hugh Archer, executive director, Kentucky Natural Lands Trust

Barry Barker, executive director, Transit Authority of River City

Margaret “Peggy” Plympton, deputy chairman, National Endowment for the Humanities

Dr. Mahendra Sunkara, director, Conn Center for Renewable Energy Research, U of L

Burt Lauderdale, executive director, Kentuckians for the Commonwealth (environmental and social justice group)

Timothy (Tim) State, enterprise vice president, associate health and well-being, Humana Inc.

Barry Gottschalk, president and CEO, American Lung Association of the Midland States

David Tandy, president. Louisville Metro Council

Craig Anthony Arnold, chair, Center for Land Use and Environmental Responsibility, U of L

Dr Cary Sennett, president and CEO, Asthma and Allergy Foundation of America

OBSERVERS:

Charles “Chuck” Lambert, Humana VP and chair, Louisville Sustainability Council

David VanSIckle, cofounder and CEO, Propeller Health

Paul Tarini, senior program officer, Robert Wood Johnson Foundation

Ben Reno-Weber, director, Greater Louisvile Project

Tad Waddington, CEO, lasting Contribution Inc.

Gordon Garner, president, Kentucky Waterways Alliance

Andrew Smith, student

Stephanie Sido, aide-de-camp, Gen. Horoho

Robert Connolly, chair, Stites & Harbison law firm

Wes Jackson, president, The Land Institute

Deena Adams, development manager, American Lung Association in Kentucky

Dr. Rose Marie Robertson, chief science officer, American Heart Association

Dr. John Johnston, co-director, Norton Hospital Leatherman Spine Center