New ad blames problems of Ky. hospitals entirely on Obamacare; they say it's only partly to blame, but worry about future impacts

By Al Cross
Kentucky Health News

A new ad in the race for governor says "There's a crisis in our hospitals" in Kentucky, and blames it entirely on the federal health-care reform law. That is not true, according to the hospitals themselves.

The TV commercial is from Americans for Prosperity, a group supported by the Koch brothers, Wichita-based industrialists who have become major financiers of conservative campaign causes. It attacks Attorney General Jack Conway, the Democratic nominee for governor, as a supporter of Obamacare. It resembles ads run by the Republican Governors Association, but makes a stronger claim.

The ad says, "There's a crisis in our hospitals. Billions in cuts. Services shut down. Premiums are skyrocketing. And now, it's costing us jobs. The reason? Obamacare."

The ad cites no source for the "costing us jobs" claim. Overall health-care employment in Kentucky is up, but hospitals in the state have cut their number of employees by about 6.5 percent in the last three years, with total jobs declining to 72,000 from 77,000.

The Kentucky Hospital Association does give Obamacare part of the blame for that, but its recent report on the financial challenges of hospitals said the law is only part of “major changes in the health system,” including the managed-care system that the state instituted for the federal-state Medicaid program in 2011. The decline in total hospital employment in Kentucky began about nine months later.

Most of the hospitals’ layoffs have not been a result of Obamacare, but “a changing scene in health care, with more focus on the outpatient area,” which started long before the law took effect, KHA President Michael Rust said this month. One of the law’s aims is to further reduce expensive use of hospitals, which Americans and especially Kentuckians use too much.

“Our concern is moving forward,” Rust said, noting the law’s impending cuts in special Medicaid payments that many hospitals get for treating a disproportionate share of poor patients – many of whom are now on Medicaid because Gov. Steve Beshear used the reform law to expand eligibility for the program to 138 percent of the federal poverty level.

The law’s intent “was that the cuts would be offset, for the most part, by health-care payments from people who had previously been uninsured,” the KHA report noted. National estimates were that “half of the newly insured would be covered by private insurance and the other half by expanded Medicaid,” but because Kentucky is a poor state, 75 percent of the newly covered are on Medicaid.

“The expansion has helped the hospitals in the state of Kentucky,” so they want to keep it, Rust said. However, they note that Medicaid covers only 82 percent of the cost of care, putting them in a financial bind. State officials say hospitals are writing off much less bad debt because more patients have insurance (82 percent being better than 0 percent), but hospitals say the problem has not abated because many patients can’t pay the high deductibles and co-payments of their Obamacare plans.

Christian Hertenstein, spokesman for Americans for Prosperity's Kentucky chapter, acknowledged in an email that hospitals are affected by other factors. "We are not in disagreement with providers that poor-decision making in Washington and Frankfort over several decades has led to serious problems," he wrote. "We are asserting that Obamacare has burdened an already burdened system with a new crisis."

As for the ad's "premiums skyrocketing" line, one Kentucky insurer, the nonprofit Kentucky Health Cooperative, will increase its premiums 25 percent (4 percent for small groups) in the next open enrollment that begins Nov. 15. The average individual premiums of one insurer, WellCare, are going down 11 percent next year while others are going up: Anthem 12.2 percent (0.4 percent for small groups), CareSource 11.8 percent, and Humana 5.2 percent (7.8 percent for small groups).

The co-op is raising rates to make up for a $50 million loss in its first year of operation. It has been funded by federal loans authorized by the reform law, which aimed to use the co-ops to create more competition for private insurance companies. The co-op sold 75 percent of the policies sold through the state's Kynect insurance exchange, and its officials say it got too many sick people, whose claims were more than expected, requiring it to place much money into a solvency fund to cover future claims.

The commercial notes that Conway "supported Obamacare" and did not join other attorneys general in a lawsuit against it. Conway's campaign called the ad "false" but did not say what it considered false, Sam Youngman reports for the Lexington Herald-Leader.

Conway spokesman Daniel Kemp said the ad is false because "It badly misrepresents Jack Conway's proven record of putting Kentuckians over partisan politics, and the ad contains numerous misrepresentations about healthcare in Kentucky." He cited the Courier-Journal article that quoted Rust and examined the claims made in the Republican Governors Association ads.

Republican nominee Matt Bevin initially called for immediate elimination of the Medicaid expansion, and Conway made that "part of his stump speech, accusing ... Bevin of being 'callous' for wanting to 'kick a half a million' Kentuckians off of their health insurance," Youngman notes.

After state Senate President Robert Stivers, R-Manchester, said the legislature would decide Medicaid policy and would look at making Kentucky's program more like Indiana's, Bevin said he would look to states like Indiana in making revisions and wouldn't immediately end the expansion.

Bevin has called "nonsense" the state-funded study by Deloitte Consulting that said the expansion would pay for itself through 2020 by adding patients to the health-care system, creating jobs and generating tax revenue.

Conway has said that if the expansion doesn't pay for itself, the state will have to look for ways to reduce its cost. The federal government is paying the entire cost of the expansion through next year, but states will begin paying 5 percent in 2017, rising in steps to the law's limit of 10 percent in 2020.

The new TV ad is part of a campaign that "will be accompanied by mailings and a grass-roots component, with a goal of knocking on several thousand doors within the next three weeks," Youngman reports.

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

Beshear keeps up defense of Obamacare, McConnell gives only a short rebuttal at State Fair breakfast

Democratic Gov. Steve Beshear and Republican U.S. Sen. Mitch McConnell traded views on health-care reform at the Kentucky Farm Bureau's country-ham breakfast at the Kentucky State Fair, but McConnell made much less of the issue than he had in previous years.

"The governor and I have debated Obamacare at this breakfast the last two or three years," McConnell said, well into his 11-minute speech, which followed Beshear's. "I’ll spare you my rebuttal other than to say higher premiums, higher co-payments, higher deductibles, lost jobs and a big bill coming to state government for Medicaid expansion in a couple of years."

Earlier, Beshear won applause from Thursday's crowd of 1,500 when he pointed out that the share of Kentuckians has been reduced by 56 percent through "our aggressive embrace of federal health reform." He added, "And we’ve done so without jeopardizing our budget. Oh, I know, I know the political rhetoric you hear from health-reform opponents who say it’s costing us thousands of jobs and we’re gonna bankrupt our state. Well, as I’ve said a lot of times, everybody is entitled to their own opinion but nobody is entitled to their own facts."

Beshear cited the state-funded study by Deloitte Consulting, which found that "Kentucky actually created 12,000 new jobs in the first full year of health-care reform, and it’s predicted to create over 40,000 new jobs by 2021." Those figures do not reflect job losses at hospitals, which blame Medicaid managed-care companies and health reform for layoffs.

"Instead of bankrupting our state, Deloitte’s report predicts a positive 820-million-dollar impact over eight years on state and local governments," Beshear said. That prediction is based on the belief that the Medicaid expansion is increasing health-care payrolls and generating more tax revenue; in 2021, the last year for which Deloitte made predictions, it said the expansion would cost more than it brings in.

Beshear expanded Medicaid eligibility to households with incomes up to 138 percent of the federal poverty level. The federal government is paying the entire cost of the newly eligible through 2016; in 2017 states will begin paying 5 percent of that cost, rising in steps to the law's limit of 10 percent in 2020.

Defending his decision, Beshear said, "There is a direct line from poor health to almost every challenge that Kentucky faces: whether that's poverty, unemployment, lags in educational attainment, substance abuse or crime. Our aggressive embrace of federal health reform has brought health-care coverage to over a half a million more Kentuckians, including many farm families."

Alluding to the Nov. 3 election that will choose his successor, Beshear said, "There is no doubt that we are headed in the right direction at a very rapid pace. And we need to accelerate that momentum, for all of our sakes, instead of going back to the Dark Ages. Now, some people refused to acknowledges these accomplishments, or they try to put partisan spin on them. As we know this is the silly season, campaign season, and some people can’t help themselves. But the fact is, Kentucky is back."

(McConnell, Beshear and Louisville Mayor Greg Fischer agreed on at least one thing: Agriculture Commissioner James Comer, who lost the Republican gubernatorial primary by 83 votes to Matt Bevin, has done a great job. "You inherited a mess, and you cleaned it up, and you ran an outstanding department," McConnell said.)

In his weekly commentary the next day, Beshear noted the big increase in preventive screenings of Medicaid clients: "No longer are their medical choices limited to emergency-room or charity medical visits."

Republican senator suggests expanding Kynect to other states to help pay state's coming share of Medicaid expansion

By Melissa Patrick
Kentucky Health News

While the Republican nominee for governor says he would dismantle the state health-insurance exchange branded as Kynect, a GOP senator is talking about not only keeping it, but expanding it to other states to pay for the other big feature of federal health reform: expanded Medicaid.

Sen. Ralph Alvarado of Winchester made the suggestion at a legislative committee meeting where Kynect Director Carrie Banahan said it would be "disastrous" to move Kentuckians to the federal Obamacare exchange, as Republican gubernatorial nominee Matt Bevin has said he will do if elected.

Sen. Ralph Alvarado

Alvarado, a physician, said his concerns about Obamacare in Kentucky are mostly monetary because the state will have to start paying 5 percent of the Medicaid expansion costs in 2017, rising to the reform law's limit of 10 percent in 2020.

"We are looking at about a little over one billion dollars to find between 2017 and 2021, and we are going to have to find a way to pay for that," Alvarado said, noting that around $250 million will be needed in the two-year budget that begins July 1, 2016. "I'd like to find a way that we are going to pay for that."

Democratic Gov. Steve Beshear, who expanded the Medicaid eligbility ceiling to 138 percent of the federal poverty level, cites the prediction in a state-funded study by Deloitte Consulting that the expansion will add a net $820 million to the budget through 2021 by adding more patients to the health-care system, generating jobs and tax revenue. Republicans remain skeptical.

Alvarado suggested that Kynect become a regional exchange and charge other states for its services, using the profit to pay for the expansion.

"There are states that want a good state exchange, but haven't been able to run one. And there are several that are about to expand Medicaid and are looking at the federal exchange," he said. "So my thought was, why not approach those states that are going to expand Medicaid, offer to do the same services that a federal exchange would do, and run the exchange for them for a fee?"

Alvarado said that he is "not a supporter of Obamacare" or the way Beshear implemented it without legislative involvement, but "The Supreme Court has made its decision, it is going to be here," so he said that as a member of the Senate and its budget committee, he would offer his concept and move forward.

"I've been encouraged that there has been bipartisan approval of all this so far," Alvarado said. "I haven't had anyone say, that is a bad idea." He said Beshear Chief of Staff Larry Bond had called it a "novel idea."

Banahan said of the idea, "It took lots of planning and discussion for us to create this state-based exchange and to determine whether we should embark on creating a regional exchange is not as simple as it seems. It is not something we could move on quickly." There are no regional exchanges, but the law provides for them.

Rep. David Watkins, D-Henderson, said, "I think that his proposition surely should be looked at, but I think it would be looked at much more favorably in the context of our new governor intending to keep Kynect, rather than dismantling it."

Alvarado raised the idea at the Thursday, Aug. 27 meeting of the Budget Review Subcommittee on Human Resources, where Banahan, executive director of the Kentucky Health Benefit Exchange, gave a presentation.

Her advice: "Do not dismantle Kynect. We have one of the best exchanges in the nation. We have received all kinds of awards. Other states seek our advice. Even the federal exchange calls us for advice. Other states are utilizing or want to utilize our IT code . . . and we are self-sustaining. It would be disastrous for Kentuckians if we moved to the federal exchange."

Understanding Kynect

Under the Patient Protection and Affordable Care Act, states were given the choice of joining the federal exchange, creating a state-based exchange or using hybrid options to create an online marketplace to shop for health insurance.

Kentucky chose to create its own exchange on the advice of hospitals, insurance companies and other business interests, Banahan told the panel. "Kynect is an exchange built by Kentuckians, for Kentuckians," she said in a telephone interview. "Kynect was developed with a wide range of stakeholders. Early on we engaged advocates, insurers, agents, health care providers and businesses, and with their input, tailored our exchange to meet their needs."

Banahan's presentation described the federal exchange as generic and inflexible, and Kynect as tailored and flexible. "With a federal exchange, it's a one size fits all approach with no flexibility," she said.

She noted that because of Kynect's autonomy, "We are able to customize for Kentuckians our website and system functionalities, our outreach and education programs, (our) marketing (and our) call-center services.

"As a federal exchange, Kentucky would lose its authority and control to make decisions that impact Kentuckians. . . . Once you lose your authority and control you lose the ability to be informed about what is going on. We would also no longer be unable to intervene or assist individuals and insurers with enrollment problems or issues."

Banahan also noted that funding for kynectors, people who help individuals learn about their health-insurance options, would be reduced by 75 percent if Kentucky moved to the federal exchange. Kynectors held more than 3,000 enrollment, education and outreach events in 2014, she said.

"We don't believe they would provide the statewide services that we have today," Banahan said. With the state based exchange, "We have kynectors in all 120 counties."

Banahan said both agents and insurers are happy with Kynect, and the unique "dashboard" that it offers agents has helped them grow their business by 30 percent -- and the eight insurers that have signed up with Kynect in 2016 have said they probably would not follow Kentucky to the federal exchange. (Corrected Oct. 16, 2015)

Show us the money

Federal money helped start Kynect, but the exchange was set up to be self-sustaining, and is now funded entirely through a 1 percent assessment on insurance policies that the companies pass on to customers. The federal exchange charges a 3.5 percent assessment.

Kynect's budget for the current fiscal year is $26.9 million, according to the presentation.

Banahan said no state has dismantled a "working and successful" exchange, but four failed ones were decommissioned at costs ranging from $5 million to $22 million.

While the total cost of dismantling Kynect is unknown, vendors have projected that it will cost $23 million for IT work alone, Banahan said. "Once we started to decommission Kynect, we believe that cost would be significantly higher."

Alvarado said he was disappointed that Banahan's presentation didn't include information about what it would cost Kentucky annually to participate in the federal exchange, because he had requested that information when he called the meeting.

"For the second time, they could not provide me an answer to that," he said, referring to the Joint Health and Welfare Committee meeting in July, when he said he had pushed Beth Jurek, executive director of the Cabinet for Health and Family Services' budget and policy office, for the same information.

Asked if she had this information, Banahan said, "The governor made an early decision to establish the state exchange; therefore, we did not develop any cost for the federal exchange." She added later, "We never contemplated that we would be part of the federal exchange so we never developed any type of cost, so those numbers aren't available."

Non-profit hospitals in Flemingsburg and Horse Cave become part of larger groups in order to stay open

Two more rural Kentucky hospitals, Caverna Memorial Hospital in Horse Cave and Fleming County Hospital in Flemingsburg, are merging with larger hospital groups in an effort to make ends meet.

“Significant regulatory changes brought about by the Affordable Care Act and payment reform at the federal and state level make it increasingly difficult for small rural hospitals to remain independent,” Caverna CEO Alan Alexander said in a news release.

In a merger expected to be complete by year's end, not-for-profit Caverna will join not-for-profit Commonwealth Health Corp., the parent company of The Medical Center at Bowling Green and will change its name to The Medical Center at Caverna, Alyssa Harvey reports for the Bowling Green Daily News.

Commonwealth will then operate five acute-care hospitals in Southern Kentucky, including The Medical Center at Franklin, The Medical Center at Scottsville and the Commonwealth Regional Specialty Hospital in Bowling Green.

Caverna, a 25-bed, critical-access hospital, was named one of 15 rural hospitals in "poor financial health" by State Auditor Adam Edelen in a report last year.

The report said rural hospitals struggle with high administrative costs associated with Medicaid managed care, higher-than-average penalties from Medicare for readmitting patients within 30 days, managed-care policies related to emergency room visits that often didn't cover the cost of care, and ongoing complaints of slow, low or denied payments from the managed-care organizations.

MCOs in Kentucky signed new contracts with the state this year that addressed many of these issues, but these new contracts only went into effect July 1.

Edelen's report said that to survive, some hospitals would have to change their business models, and merging with larger hospitals could be an option.

Rural hospitals in Nicholas and Fulton counties have closed in the last year.

"I see it as a trend. The industry is going through some very rapid and massive changes," Alan Palmer, director of marketing at TriStar Greenview Regional Hospital, told Harvey for a separate article. "A lot of pressures are being put on smaller or rural facilities. It's a matter of survival and these smaller communities believe they deserve to have a health care facility in their communities."

Palmer noted that HCA, Greenview's parent company, has a spinoff company called LifePoint Health that owns rural hospitals.

LifePoint announced earlier this month that it had acquired Fleming County Hospital, which had been listed in "fair financial health" in Edelen's report.

Fleming County Judge-Executive Larry Foxworthy, who sits on the hospital board as a non-voting member, told Christy Hoots of The Ledger Independent in Maysville that the facility had struggled since it was built in 2008.

"Reserves are down," Foxworthy said. "Unless something is done, the hospital may go bankrupt. We don't want to see that happen. We need to make sure the hospital stays open and has a presence in Fleming County."

LifePoint owns nine other Kentucky hospitals: Bluegrass Community Hospital in Versailles; Bourbon Community Hospital in Paris; Clark Regional Medical Center in Winchester; Georgetown Community Hospital in Georgetown; Jackson Purchase Medical Center in Mayfield; Lake Cumberland Regional Hospital in Somerset; Logan Memorial Hospital in Russellville; Meadowview Regional Medical Center in Maysville; and Spring View Hospital in Lebanon.

The Daily News reported that T.J. Samson Community Hospital in Glasgow, a nonprofit that has chosen to not merge with a larger hospital, has cut between 39 and 49 employees and made salary adjustments in all departments in 2014. It also offered about 45 employees early retirement, of which about 24 people, including then-CEO Bill Kindred, accepted.

Health care industry ranks first, by far, in legislative lobbying since '93; insurance second, tobacco third; drugmakers' rank a mystery

By far, health-care interests have spent the most on lobbying the General Assembly since the Legislative Ethics Commission was created 22 years ago, Jonathan Meador of Insider Louisville discovered among many other things as he crunched the data filed by lobbying interests over the years.

"The most dominant industries in Kentucky in terms of lobbying dollars have been, by far, the health care and health insurance sectors, comprised primarily of for-profit HMOs and to a lesser extent hospitals, many of which are listed in their own category within the larger dataset," Meador reports.

Health care accounted for almost 23 percent of lobbying expenses categorized by Meador, while insurance totaled 11 percent. Tobacco, the cause of many of Kentucky's health problems, ranked third, just behind insurance. Most of the tobacco lobbying in Kentucky is done by Altria Group, parent firm of Philip Morris Cos., makers of Marlboro and other cigarettes. It has lobbied against a statewide smoking ban with the help of the Kentucky Farm Bureau Federation, a big insurance interest.

One other major category, "pharmaceutical issues," made the Insider Louisville pie chart, at 6.8 percent. It would have been much larger had it included advertising by the Consumer Healthcare Products Association, which ran radio ads before and during legislative sessions encouraging listeners to ask legislators to vote against bills to limit the sales of pseudoephedrine, a key ingredient in making methamphetamine. At the time, such advertising did not have to be reported; now it does.

Meador notes that the "nonprofit" designation "can include everything from conservative anti-abortion groups to the progressive Kentuckians for the Commonwealth, and even well-heeled professional membership organizations like the Kentucky Medical Association." While KMA is a health-care organization, doctors and health-care businesses don't always agree on issues.

Meador also notes that "Chamber of Commerce" in the chart includes local chambers as well as the Kentucky Chamber of Commerce, which usually spends more than any other particular lobbying organization. The figures do not include lobbying of the executive branch, which is monitored by the Executive Branch Ethics Commission.

Study finds that teens who use e-cigarettes are more than twice as likely as non-using teens to start smoking tobacco products

image: usnews.com

Teens who use electronic cigarettes may be more than twice as likely to start smoking tobacco than those who have never used the devices, according to a study at the University of Southern California.

“Recreational e-cigarette use is becoming increasingly popular among teens who have never smoked tobacco," Adam M. Leventhal, lead author of the study, said in a news release. "Adolescents who enjoy the experience of inhaling nicotine via e-cigarettes could be more apt to experiment with other nicotine products, including smokeable tobacco.”

E-cigarettes are battery-powered devices that deliver nicotine through a vapor by heating a solution of propylene glycol or vegetable glycerin, flavoring and other additives.

The study, published in the Journal of the American Medical Association, followed a group of about 2,500 Los Angeles ninth graders at 10 public high schools and surveyed them about their tobacco and e-cigarette use three times in a year. At the start of the study, 222 of the students had used e-cigs, but not traditional cigarettes, and 2,308 had smoked neither.

The study found that e-cigarette users were almost four times more likely than those who had never tried them to have smoked combustible tobaccos, such as cigarettes, cigars and hookahs, within six months (30.7 percent vs 8.1 percent, respectively) and more than twice as likely in 12 months (25.2 percent vs 9.3 percent, respectively).

The findings are important because teen e-cigarette use tripled between 2013 to 2014, surpassing teen use of all tobacco products. Nationwide, 13.4 percent of high-school students reported smoking e-cigs and 3.9 percent of middle-school students in 2014, according to a report by the Centers for Disease Control and Prevention.

“While teen tobacco use has fallen in recent years, this study confirms that we should continue to vigilantly watch teen smoking patterns,” Nora D. Volkow, director of the National Institute on Drug Abuse, said in the press release. “Parents and teens should recognize that although e-cigarettes might not have the same carcinogenic effects of regular cigarettes, they do carry a risk of addiction.”

The researchers acknowledge that their study doesn't prove that e-cigarettes cause teens to start smoking cigarettes, but they say that it is a possibility, and further research is needed to confirm their findings.

In a separate JAMA editorial, Nancy A. Rigotti, an author of the study, calls for prompt marketing regulations by the U.S. Food and Drug Administration to stop e-cigarettes from being marketed in ways that appeal to children and adolescents. "A rational approach is to extend to e-cigarettes the same sales, marketing, and use restrictions that apply to combustible cigarettes," she writes.

The FDA has been working on regulations for e-cigarettes since April 2014.

Legislative leaders debate future of Medicaid expansion

"There’s no doubt that health care remains a significant issue for politicians and voters in the commonwealth. While thousands of Kentuckians have health insurance for the first time, Frankfort continues to debate questions about the quality and affordability of medical services provided under the Affordable Care Act and the cost of expanded Medicaid coverage."

That's how Kentucky Educational Television summed up the health-care discussion among the General Assembly's top leaders on the Aug. 24 episode of "Kentucky Tonight," the state network's weekly issue-oriented discussion show:

The biggest health-care question for the legislature and the new governor will be whether to continue or change the state's expansion of eligibility for the federal-state Medicaid program under federal health reform. The federal government is paying the entire cost of the expansion, which covers about 400,000 people, but the state will have to start paying 5 percent of the cost in 2017, rising to the law's limit of 10 percent by 2020.

House Speaker Greg Stumbo, D-Prestonsburg, said on "Kentucky Tonight" that the question will need close scrutiny, especially because many more people enrolled in Medicaid more quickly than expected, but under the current law, the state needs to keep the current system.

“The economy is good in Kentucky right now,” Stumbo said. “We can afford to provide this insurance, we can afford to continue to make sure that Kentuckians have it, we just have to monitor it and make sure we’re doing it efficiently.”

House Minority Leader Jeff Hoover, R-Jamestown, said he is concerned that the system isn't sustainable because more people are seeking care and providers are facing reductions in Medicaid reimbursements.

“There are a lot of rural hospitals, particularly in my area and I think in other areas of the state, that are struggling financially now as much or more than any time in many, many years,” Hoover said. He said they are “constantly having to fight for every service that’s provided with the insurance companies [and] the managed-care companies,” which oversee the care of Medicaid clients much like private insurance does.

Senate Minority Leader Ray Jones, D-Pikeville, said he hasn’t heard such concerns, and noted that his wife is a primary-care physician in Pike County. He said he worries about proposals by Matt Bevin, the Republican nominee for governor.

“If you do away with Kynect and you roll back the Medicaid expansion, not only are those people going to be hurt, but the local health-care providers that are going to have to continue to treat these people if they show up in the emergency room and they don’t have a way to pay for it, then . . . you’re going to see an increase in charity care.”

Senate President Robert Stivers, R-Manchester, said a recent visit to Manchester Memorial Hospital "reinforced for him the need to dissuade the newly insured from using emergency rooms as source for primary care," KET reports.

Stivers repeated his suggestion, first made to Kentucky Health News a month earlier, that Kentucky consider a Medicaid system more like that in Indiana, "which provides incentives for Medicaid patients to see their family doctor or go to an urgent care clinic rather than going to an ER for non-emergency concerns," KET reports.

After Stivers made that suggestion, Bevin backed off his earlier statement that he would end the expansion immediately if elected, and said he favors a modified plan based on the experience of other states such as Indiana.

Attorney General Jack Conway, the Democratic nominee for governor, and Drew Curtis, the independent candidate, have said they favor the Medicaid expansion, but Conway has said it would have to be scaled back if it doesn't pay for itself by adding health-care jobs and creating tax revenue, as a state-funded study by Deloitte Consulting predicted in February.

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

Kentucky will get money to increase colon cancer screenings in Louisville and Appalachia, which lag behind recent success

By Melissa Patrick
Kentucky Health News

Kentucky will receive about $2.6 million in federal money over five years to help fight colon cancer by encouraging people to be screened for it, with a focus on populations in Louisville and Appalachia.

"Those regions have large numbers of underserved, underscreened residents," Gov. Steve Beshear said at a press conference. Screening rates are lower among African Americans, men, the poor and the less educated.

Lt. Gov. Crit Luallen, a colon-cancer survivor, said "Colon cancer is the one cancer we can prevent through early screening and detection. And if it is caught early, it can be treated effectively."

According to the federal Centers for Disease Control and Prevention, the five-year survival rate for colon cancer is 90 percent when it is found and treated early. In 2013, the last year for which data are available, Kentucky ranked first in colon cancer and fourth in colon-cancer deaths, according to the Colon Cancer Prevention Project.

This Kentucky Cancer Consortium graph shows the
deaths from cancers with evidence-based prevention
or early detection methods in Kentucky in 2005-09.

Kentucky has both the highest rate of new cancers and deaths from cancer in the nation, many of them preventable through early screening and detection. But preventive screening among those who have recently gotten insurance for the first time and those without insurance is not the norm, partly because people who have been accustomed to getting health care only when something seems wrong often don't understand the importance of preventive screening or that these services are provided free of charge if they have Medicaid or private insurance.

A recently reported CDC study found that Americans with insurance or with higher incomes were up to three times more likely than those without coverage or with lower incomes to receive preventive screenings and services, which has certainly been the case with Kentucky's expanded Medicaid population.

A Department for Medicaid Services report found that preventive screenings rose sharply in 2014 among Medicaid recipients in Kentucky: colorectal cancer screenings rose 108 percent to 35,633; breast cancer screenings rose 111 percent to 51,292; cervical cancer screenings rose 88 percent to 78,281;cholesterol screenings rose 111 percent to 170,514; preventive dental services rose 116 percent to 159,508, to name a few. This increase in preventive care is expected to improve the future health outcomes of Kentuckians and to help decrease future cost by catching problems earlier.

Kentucky has made great strides in fighting colon cancer.

In 2002, the Kentucky Cancer Consortium began an initiative that brought more than 60 different agencies and organizations together to fight colon cancer. At the time, Kentucky's colorectal-cancer screening rate was next to lowest in the nation, said Dr. Tom Tucker, senior director for cancer surveillance at the University of Kentucky's Markey Cancer Center and director of the Kentucky Cancer Registry.

Seven years later, the screening rate rose from one-third of the eligible population (those are 50 or older) having ever been screened to nearly two-thirds. This caused a 24 percent decrease in the incidence of colorectal cancer and a 28 percent drop in deaths from the disease, Tucker said.

"A 24 percent decrease in incidence means that each year 230 Kentucky residents who would have been diagnosed with colorectal cancer no longer get the disease," he said.

"This is a remarkable public-health accomplishment," Tucker said. "But we are clearly not done," since the state still ranks first in colon cancer. "The new grant just announced by the governor will be an essential resource in helping us reach this last one-third of the eligible Kentucky population with lifesaving colorectal screening."

Since 2012, Kentucky has also provided colorectal screenings to the uninsured through a partnership with the nonprofit Kentucky Cancer Foundation, which matched $1 million in state funds in both 2012 and 2014 to pay for the program.

This year, the legislature passed a law to make sure doctors are coding colonoscopies as screening and not diagnostic, to make sure patients are not charged for the procedure.

Another effort to combat cancer in Kentucky is through the Horses and Hope Program, led by First Lady Jane Beshear, who, along with the Kentucky Cancer Program, Kentucky One Health and the University of Louisville's James Graham Brown Cancer Center, is working to raise $1 million for a mobile cancer screening unit which will provide free or reduced-cost cancer screenings across Kentucky.

“Kentucky has transformed into the state with the broadest number of colon-cancer screening options and the lowest barriers for colon-cancer screening,” said Dr. Whitney Jones, founder of the Colon Cancer Prevention Project and co-founder of the Kentucky Cancer Foundation. "Hopefully, we will be one of the first Southern states, if not the first state, to screen 80 percent of our population by 2018."

Writer considers salad a wasteful luxury, and not all that nutritious

Salads should be considered a "resource-hungry luxury" instead of a staple because they offer little nutritional value, require "precious crop acreage" to grow, requires fossil fuel and refrigeration to ship, is the top source for food waste and a top transporter of food born illnesses, Tamar Haspel writes for The Washington Post .

"As the world population grows, we have a pressing need to eat better and farm better," Haspel writes.

Haspel notes that while she has pointed out problematic foods such as almonds, for their water use; corn, for the monoculture it encourages; and beef, for greenhouse gases from cattle, "none of them is a clear-cut villain," unlike salad, which "has almost nothing going for it." She backs up her claim with these arguments:

Salad is mostly water: Haspel writes that a nutrient quality index that rates foods based on how much of 27 nutrients they contain per 100 calories found "four of the five lowest-ranking foods (by serving size) are salad ingredients: cucumbers, radishes, lettuce and celery. (The fifth is eggplant.)" This is because they are 95 to 97 percent water, unlike other more nutritious vegetables like the sweet potato, which is only 77 percent water. "A head of iceberg lettuce has the same water content as a bottle of Evian (1-liter size: 96 percent water, 4 percent bottle) and is only marginally more nutritious."

Salad fixings are expensive, with little nutrition: "The makings of a green salad — say, a head of lettuce, a cucumber and a bunch of radishes — cost about $3 at my supermarket," she writes. "For that, I could buy more than two pounds of broccoli, sweet potatoes or just about any frozen vegetable going, any of which would make for a much more nutritious side dish to my roast chicken."

Eating less salad saves the planet: "When we switch to vegetables that are twice as nutritious — like those collards or tomatoes or green beans — not only do we free up half the acres now growing lettuce, we cut back on the fossil fuels and other resources needed for transport and storage."

Salad add-ins can make you fat: "Lots of what passes for salad in restaurants is just the same as the rest of the calorie-dense diabolically palatable food that’s making us fat, but with a few lettuce leaves tossed in. I won’t be the first to point out that items labeled 'salad' at chain restaurants are often as bad, if not worse, than pastas or sandwiches or burgers when it comes to calories."

"Take Applebee’s, where the Oriental Chicken Salad clocks in at 1,400 calories, and the grilled version is only 110 calories lighter. Even the Grilled Chicken Caesar, the least calorific of the salads on the regular menu, is 800 calories. Of course, salad isn’t always a bad choice, and Applebee’s has a selection of special menu items under 550 calories (many chain restaurants have a similar menu category)."

Lettuce is the top source of vegetable food waste and food borne illnesses: "It’s the top source of food waste, vegetable division, becoming more than 1 billion pounds of uneaten salad every year," and "According to the Centers for Disease Control (and Prevention), green leafies accounted for 22 percent of all food-borne illnesses from 1998-2008." (Leafy vegetables also include cabbage, spinach and other kinds of greens.)

Haspel says she loves a good salad as much as anyone, and recognizes that as a filler it has kept her from eating too much calorie-dense food, but she concludes, "As we look for ways to rejigger our food supply to grow crops responsibly and feed people nutritiously, maybe we should stop thinking about salad as a wholesome staple, and start thinking about it as a resource-hungry luxury."

Free workshop on health coverage in Louisville Sept. 21; free lodging available to registrants who need to come the night before

Journalists covering health issues in Kentucky, from drug abuse to health reform, have a chance to immerse themselves in the subject at a free one-day workshop in Louisville on Sept. 21.

The workshop is sponsored by the Foundation for a Healthy Kentucky, which is also offering free hotel lodging to registrants whose distance from Louisville would make it inconvenient for them to get there by 9 a.m. EDT, when the workshop will begin.

The workshop is designed to help journalists cover health in ways that your readers, viewers and listeners will appreciate. It will feature a collection of America’s and Kentucky’s top health experts and health journalists. The program should yield terrific stories at the same time it helps you see how to make health coverage a more central part of what your newsroom does every day. The speakers will be:

• Dr. Nora Volkow, head of the National Institute on Drug Abuse, to talk about the opiate epidemic nationwide, why it's even worse in Kentucky, and specific stories you could and should be doing but probably aren’t.
• Bill Wagner, head of Louisville's Family Health Centers, to discuss the state of health reform in Kentucky and obstacles that remain.
• A patient of Wagner's clinic who is newly insured, to talk about what works with the reforms and what needs further reform.
• Abby Goodnough, national health reporter for The New York Times, to talk about her award-winning series on health reform that focused on Kentucky and lessons it holds for you.
• Laura Ungar, health reporter for USA Today and The Courier-Journal, to talk about what stories she'd do based on that day's session, and how to sell editors on health stories and a health beat.
• Mary Meehan, health reporter at the Lexington Herald-Leader who just began a Nieman fellowship at Harvard University, will talk about how to bring new life to the medical beat at media outlets that increasingly are stretched thin.
• Al Cross, director of the Institute for Rural Journalism and Community Issues, to discuss where the reform law works, where it needs fixing, and what to ask gubernatorial candidates in the upcoming election.
• Larry Tye, author and former reporter at The C-J and The Boston Globe, will moderate the sessions to keep the focus on making these issues resonate with your readers and listeners. He runs a Boston-based health reporting fellowship that Mary and Laura did, and where Nora and Abby were speakers.

"Larry Tye assembled what we think is a first-rate line-up of health officials and medical journalists to help you think about how to make health stories resonate with your editors and your readers," Cross said. "If you agree, sign up now because there's limited space and a growing list of registrants. Our speakers are the stars, but you will be the focus of the day's program."

Register for the free workshop and lodging at www.regonline.com/healthcoverageworkshop. Questions can be directed to Angela Koch at akoch@healthy-ky.org.

Stanford doctor starts local 'Get Healthy Lincoln County' program, plans to take it statewide via Kentucky Medical Association

Part of the effort: A weekend workout group in Stanford

A Stanford physician who started a local movement for a healthier community plans to promote it statewide through the Kentucky Medical Association’s Commission on Public Health.

"Dr. Naren James said in the next year, under the Affordable Care Act, health insurance rates will be affected by the overall health of a community," Abigail Whitehouse reports for The Interior Journal. “Having a healthier community will actually have a tangible impact on people’s health insurance rate,” James told her.

James said he was motivated to start the program when he realized that that Kentucky ranks very high in childhood obesity, "which ultimately effects the future of a community," Whitehouse notes. Much of the program's focus is on increasing residents' physical activity.

“The reason why we did ‘Get Healthy Lincoln County’ was to make a model that could be used statewide,” James told her. She writes, "His goal is to promote the movement so that every community in Kentucky can find a coalition of people interested in health to create that 'get healthy' community."

“It has to be from the ground up, not from the top down,” James said. “When you deal with health, people have to make the choice. It has to be educational.”

In June, the program conducted several activities, "many of which were successful," Whitehouse reports. "Now that the 'Get Healthy Lincoln County' movement has been approved as an annual effort, James said a committee has already begun planning for next year by determining what did and didn’t work well this time around.

For example, a history walk around Stanford, Kentucky's second oldest town, "had a great turnout," James said. Also successful were "a Saturday morning of exercise" in a local park and "Dinner with a Doctor," Linda Carney of Texas, "who provided the crowd with a plant-based diet and spoke about the benefits of such diets," Whitehouse reports.

"What’s for Dinner Stanford?," a project of the local extension office, "invited the public to participate in a plant-based cooking class using local produce," Whitehouse writes. "James said that the cooking class has done well and will continue throughout the year, but it was realized that programs which require more commitment require more of a push."

For example, a program called "Eight Weeks to Wellness" needed "more events to sell it," James said. "Anything you’re going to do for several weeks, you have to sell it. . . . We need to sell it to people’s individual needs. They have to understand why health is impacting them personally."

"In a broader sense, James said people leading the 'get healthy' movement have to learn to speak the right language," Whitehouse reports. “The language about health is immediately negative,” he said. “It’s a cultural shift. Speaking about health positively is so important, which we tried to do with the Get Healthy program and I think overall it came across positively. Even the things that are negative can be turned into positive.”

Medicaid manager Passport gives $25,000 to Democratic group that has given heavily to committee backing Conway for governor

Passport Health Plan, which manages Medicaid care for hundreds of thousands of Kentuckians, gave $25,000 this year to the Democratic Governors Association, "which already this year has given $600,000 to a Democratic super PAC supporting the election of Attorney General Jack Conway as governor," Tom Loftus reports for The Courier-Journal.

"Beshear’s office and Passport Chief Executive Mark Carter both said the $25,000 was not a political contribution but a sponsorship for a one-day policy conference co-hosted by the DGA in Louisville last spring," Loftus reports. "But Senate Republican Leader Damon Thayer of Georgetown said, 'Of course the DGA wanted to do a, quote unquote, policy conference in Louisville because Kentucky is the site of the only competitive governor’s race in the country this year.'" Passport is based in Louisville.

Loftus notes that the money was requested by Democratic Gov. Steve Beshear, who objected in 2010 to Passport's "spending of Medicaid funds on things like lobbying, travel, public relations, donations and sponsorships." Beshear said it should “cease spending a single taxpayer dollar that is not absolutely necessary to provide quality health-care services to Medicaid-eligible recipients.”

Thayer said the donation was a political contribution because the DGA exists to elect Democratic governors, as it says on its website. "An agenda shows the conference involved three one-hour policy discussions on the morning of May 21 at the Galt House," Loftus reports. "Participants included Beshear, Conway and a few other Democratic governors and Democratic candidates for governor from other states." No attendance numbers were given.

In 2010, then-state Auditor Crit Luallen "questioned more than $423,000 in sponsorships and donations — many of which did not seem to advance Passport’s mission of improving the health care of Medicaid recipients. Luallen's report resulted in sweeping reforms," Loftus writes. "Carter said criticism of spending on sponsorships was valid in 2010 when Passport had an exclusive state contract to manage Medicaid in the Louisville region," but now it has to "compete with four other, very large, for-profit plans," Carter said. "Things that are inappropriate when you area sole-source contractor, like sponsorships, are almost necessities to be able to compete with Humana, Anthem and others."

Loftus reports, "Two of the big private insurance companies that hold managed care contracts in Kentucky — which unlike Passport function in many states and offer products other beyond Medicaid managed care — are listed in the report as giving more to the DGA during the first half of this year: Humana, of Louisville, is listed as having given $80,000; Anthem, of Cincinnati, gave $325,000."

Passport expanded its operations after Beshear used federal health-reform money to expand eligibility for Medicaid, increasing the program's rolls by half. Conway supports the expansion but Republican candidate Matt Bevin says it needs to be scaled back. The reform law calls for the state to start paying 5 percent of the expansion cost in 2017, rising to the law's limit of 10 percent in 2020. Beshear, citing a state-funded study; says the expansion will pay for itself; Bevin scoffs at that.

Bevin and Conway to speak, answer questions about health policy at rural-health group's meeting Sept. 18 in Bowling Green

The Kentucky Rural Health Association is hosting a "Candidates Forum on Health" Friday, Sept. 18 in Bowling Green, after the conclusion of its annual conference. All of the candidates running for all offices in November have been invited, KRHA said, but the focus will be on the two major-party candidates for governor, who will speak and answer questions in separate, back-to-back sessions.

"I hope this forum will help us have a better understanding of what the candidates' views are on health care and what their approach will be," KRHA President Dr. Brent Wright said in an interview.

Republican Matt Bevin is scheduled to speak and answer questions from 1:15 to 2 p.m., and Democratic Attorney General Jack Conway is scheduled to do likewise from 2:15 to 3 p.m. Bowling Green is on Central Time. Candidates for governor and other statewide offices will have a meet-and-greet session at 11:30 a.m., before lunch.

Wright said he was looking for candidates' views on the Patient Protection and Affordable Care Act and rural health care, "especially after the auditor put forth his report on hospitals that face financial challenges throughout the state."

Independent candidate Drew Curtis said he was not invited but would seek an invitation.

Wright said the forum offers a unique opportunity for KRHA stakeholders, who represent many different areas of health care around the state, to find out what the candidates are saying about health and get their questions answered.

"We are a group that is about advocacy and education for rural health care," Wright said. "We want to convey that rural health matters and that our membership has a voice and that our concerns need to be heard."

The public is invited to the forum. Lunch will be provided free of charge to attendees, but registration is required. Click here to register.

The forum is co-sponsored by the Foundation for a Healthy Kentucky, the Friedell Committee, the Kentucky Academy of Family Physicians, the Kentucky Coalition of Nurse Practitioners & Nurse Midwives, the Kentucky Hospital Association, the Kentucky Medical Association, the Kentucky Primary Care Association and Kentucky Voices for Health.

The Sept. 17-18 KRHA conference and the Sept. 18 forum will be held at Western Kentucky University's Knicely Center on Nashville Road, with lodging at the adjacent Staybridge Suites on Campbell Lane and the new Hyatt Place, next to the WKU campus on Center Street (with shuttle service). The registration fees until Sept. 3 are $125 for KRHA members, $200 for non-members and $45 for student members. For the draft agenda, registration form and hotel information, in a PDF, click here.

Ky. to share in $2.5 million anti-heroin grant that will pair law enforcement and public health to put more focus on treatment

Kentucky will be among several states to share a $2.5 million federal grant to help fight the heroin epidemic in its communities, according to press release from the office of Senate Majority Leader Mitch McConnell.

Heroin overdoses killed 233 Kentuckians in 2014 and 230 in 2013. Kentucky had only 22 deaths attributed to heroin in 2011, according to the state's 2014 Overdose Fatality Report.

The $2.5 million will fund the Heroin Response Strategy, a new initiative that creates a partnership among five regional "high intensity drug trafficking areas," which includes Appalachia, New England and the Washington/Baltimore; New York/New Jersey and Philadelphia metropolitan areas.

The focus of the new program is on treatment, rather than punishment, of addicts.

“It’s something different, pairing law enforcement and public health,” Van Ingram, Kentucky’s director of drug policy, told The Courier-Journal. “Just arresting and releasing people is not working real well.”

The grant will fund sharing of intelligence, analysis of trends, training of law enforcement and strengthening of partnerships between public-health and public-safety agencies. It will also support the expansion of a Drug Intelligence Officer Network in 15 states, education and training for public-safety first responders, and conferences related to public health and public safety.

In addition to the grant, the Appalachia HIDTA will receive nearly $400,000 to be used for programs to help prevent drug abuse in Kentucky, Tennessee, West Virginia, and Virginia, says the release.

New health chair of Appalachian Ky. economic group says he's a conductor, not a director; deflects query on mining's health effects

By Melissa Patrick
Kentucky Health News

Dr. William Hacker, a former state health commissioner, is the new chair of the Community Health Advisory Council for Shaping Our Appalachian Region, a non-profit organization created last year by Democratic Gov. Steve Beshear and Republican U.S. Rep. Harold "Hal" Rogers of the 5th District to improve Appalachian Kentucky's economy.

Dr. William Hacker

So, what does that mean for Hacker? And for a region with some of the worst health in the nation, so bad that it is a drag on the economy?

Hacker said in an interview with Kentucky Health News that he was still learning about his responsibilities, but felt that one of the most important skills he brings to this role is his ability to network.

"What I'm assuming my primary role will be is not so much (to be) the director as it is being the orchestra conductor," he said.

He added later, "If I can use my platform to bring people together so that they can share resources, share energy, share knowledge, share success stories. ... Even if we don't have any new dollars to spend, we may be able to have better outcomes if we know what works and make that translational across communities. ... As the old African saying goes: If you want to go fast, go alone. If you want to go far, go together."

Hacker, a native of Clay County, practiced as a pediatrician in Corbin for 18 years, spent six years with Appalachian Regional Healthcare and was the medical director for a health insurance plan.

"I have a lifelong interest in Kentucky in general, and Eastern Kentucky in particular," he said. "My roots are in Eastern Kentucky."

He began his career in public health in 2001 when he joined the state health department's Maternal and Child Health division. After 9/11/01, he established the state's first public-health disaster preparedness program. In 2004, Republican Gov. Ernie Fletcher named him commissioner, a position he kept under Beshear until he retired in 2011. Hacker holds a clinical professorship at the University of Kentucky Department of Pediatrics and is an associate professor at UK's College of Public Health.

As an active volunteer, he said that many of his current activities "deal with core issues that help address prosperity in terms of education, of economic development and of health."

With SOAR, Hacker succeeds Dr. Nikki Stone of Hazard, who left the position after the final report of her Health Working Group, which initially set two priorities: coordinated health program in schools and a study of the health effects of large-scale surface mining, which research has suggested could be significant.

When the recommendations of the health group and working groups addressing other issues were published last fall, the mining-study recommendation wasn’t included in the list, which was limited to shorter-term recommendations, but it was mentioned in the health group’s report. Some other working groups continued to meet over the winter, but the health group did not.

A representative from the federal Centers for Disease Control and Prevention, after spending three months at the SOAR Pikeville office evaluating the recommendations, announced at the May 11 "Strategy Summit" that SOAR's health focus should be on substance abuse, obesity and diabetes, with no mention of the top two recommendations made by the people in the region.

Asked if he agreed with the CDC recommendations, Hacker said, "Clearly those are three issues that need to be addressed," but he added, "I don't want to be a disease-focused program, I want to be a community-focused program that leverages all assets and resources available to deal with the social determinants of health, while also addressing those three issues."

The CDC defines social determinants of health as "the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness."

Hacker said, "The core issue of poor health, really, is not so much health, as education and economic opportunity. The tripod of prosperity is good education, good economic opportunity and good health. If you have these three components, then you can build within your community, you can recruit industry and you have an educated workforce that is healthy."

"So it is the chicken and egg thing: How do you get economic opportunity to prosper in a place that has poor health outcomes? Which comes first, and how do we do that?," he mused, while commending Rogers and Beshear on their efforts to maximize federal, state and local resources to address these core problems within Appalachia.

Hacker said that one such resource is the CDC's commitment to provide a person for one year to help bridge SOAR activities with federal resources, programs and activities. Lt. Cmdr. Jenna Meyer has already been assigned to this role and is working from SOAR's Pikeville headquarters. Meyer said she was unable to comment.

Hacker remains optimistic. "I have never seen the leadership being provided that is comparable to what Congressman Rogers and Gov. Beshear have brought to bear on the SOAR activity," he said. "I am very hopeful that SOAR will be perceived 20 years from now as a turning point in improving the prosperity of Eastern Kentucky."

Hacker said one of the Advisory Council's greatest challenges is the responsibility of "distilling down" an actionable program to improve the long-term prosperity of the region from a list of so many valid, scientifically based issues that need to be addressed.

Asked if determining the health effects of large-scale surface mining would be one of his priorities, Hacker didn't answer directly: "Any contamination of the environment is unhealthy and should be avoided when possible, whether we are talking about heavy metals or whether we are talking about second-hand cigarette smoke.

"Within the million people who live in the SOAR area, coal mining is a very important part of some communities, but not for others. So, I will certainly listen and receive input from all concerns of the communities."

He said later of SOAR, "We need to tackle issues that have the broadest reach and the greatest impact."

As for the recommendation for a coordinated children's health program, Hacker said he recognized its importance, but noted that improving health was more complex than simply changing behaviors, and emphasized the importance of getting families out of poverty as a means of improving children's health.

He also noted that "grass-roots engagement is critical to any long-term success," reflecting on a saying of Dr. Gil Friedell, founding chair of UK's Markey Cancer Center, " If the problem is in the community, then solution is in the community."

The Advisory Council decided at its first meeting Aug. 10 that each of the 11 SOAR issue groups should focus on how they could contribute to bringing more jobs to Kentucky's 54 Appalachian counties. It was also established that each of the issue groups would hold an annual roundtable to ensure community involvement.

'Snapshot' from continuing study of health reform in Ky. shows steep drop in amount of uncompensated care at hospitals

A continuing study of federal health reform's impact in Kentucky has found a big drop in uncompensated care at hospitals and broader insurance coverage than in adjoining states.

The Foundation for a Healthy Kentucky is paying the State Health Access Data Assistance Center at the University of Minnesota more than $280,000 to study how the Patient Protection and Affordable Care Act is affecting Kentuckians.

How to read this chart: While the urban and rural figures overlap,
perhaps suggesting that rural hospitals have most of the bad debts,
they are actually separate totals. So, the high of nearly $160 million
is only for the urban hospitals; the high for rural hospitals, in the same
quarter, was $130 million. The actual total that quarter: $288 million.

Under the reform law, Kentucky expanded eligibility for the federal-state Medicaid program to people in households with incomes up to 138 percent of the federal poverty level. Hospitals welcomed the expansion, because it brought more people who hadn't been getting care into the system, but say it has also been challenging because Medicaid pays about 82 percent of their cost of providing care.

State officials say, and hospitals acknowledge, that hospitals now have much less uncompensated care, or bad debts, because more people have coverage. The study's first "snapshot" of the law's impacts puts numbers on that, reporting that uncompensated care dropped preciptously when the expansion took effect in January 2014, falling to $83 million in the last quarter of the year from a high of $288 million about a year earlier.

Medicaid expansion has also helped reduce the percentage of people without health coverage more in Kentucky than in adjoining states. In December 2014, 9.8 percent of Kentuckians reported having no health coverage, well under the adjoining-state average of 12.5 percent and the national average of 12.9 percent. The figures come from The Gallup Organization, which reported last month that the Kentucky figure had fallen to 9 percent. The study did not mention the more recent figure; it was limited to impacts through the first quarter of 2015.

The study reported that during the quarter, Medicaid funded 9,314 breast cancer screenings, 4,586 hepatitis C screenings, and thousands of other preventive services," a foundation news release said. There were 5,675 cases of substance-abuse treatment, which is newly eligible for Medicaid, during the quarter.

The study also noted that Medicaid enrollment remains concentrated in Eastern Kentucky, with 32 percent of the total; greater Louisville has 19 percent. For the study presentation in graphics, click here.

Next spring, the researchers will conduct a telephone survey about the impacts of the law. “This multiyear study from a nationally known independent source will provide valuable data to inform health policy decisions,” Susan Zepeda, president and CEO of the foundation, said in the release. She told Deborah Yetter of The Courier-Journal, "We're really making a difference in the lives of Kentuckians. More people will have those health insurance cards and have access to timely health care, and that's quite a positive story."

Beshear writes reply to a Virginia newspaper, pushing Medicaid expansion like he implemented in Kentucky

Gov. Steve Beshear, trying to help a fellow Democratic governor who is trying to expand Medicaid, has written a response to an editorial in which a Virginia largest state-capital newspaper opposed the move.

"Our success undercuts your whole opposition," Beshear says in the Richmond Times-Dispatch. "Having proved from the beginning that health care reform is both the right thing and the smart thing do, Kentucky has become the poster child for why states should expand Medicaid."

The editorial cited larger-than-expected Medicaid enrollments in Kentucky and other states, but Beshear says the piece "fails to grasp both the moral and economic arguments for expansion. . . . The core tenet of health care reform is helping families and saving lives. Not vague political theory, but helping people. That’s what we’re doing in Kentucky. It’s a Christian thing."

The editorial quoted state Republican state Sen. Chris McDaniel of Northern Kentucky, chair of the Senate budget committee, as saying the costs have created "a monstrous hole" in the state budget, though the federal government is paying the entire cost through 2016. Beshear cited a state-funded study that predicted the expansion will pay for itself by creating jobs and tax revenue for four years after the state starts paying part of the cost: 5 percent in 2017, rising to the law's limit of 10 percent in 2020.

"And those numbers don’t even address the societal impact of improved health on quality of life or economic capacity, or tangible things, such as worker productivity, school attendance and public image," Beshear writes. "So, to those who claim states can’t afford expanded Medicaid, I say this: You’re entitled to your own opinion, but you’re not entitled to your own facts. The facts in Kentucky demonstrate that not only can states afford to expand Medicaid, but they also really can’t afford not to do it. Especially if they care about their people."

Democratic Gov. Terry McAuliffe, whose powers to expand Medicaid are much more limited than Beshear's has repeatedly tried to get an expansion through the Virginia legislature. At a recent National Governors Association meeting, McAuliffe told Beshear that he could use some help from him.

Researchers: Trans fats, not saturated fats, are linked to greater risk of heart disease; but no reason to eat more butter and meat

Researchers at McMaster University in Hamilton, Ont., found that trans fats are linked with greater risk of coronary heart disease and death, but saturated fats are not associated with increased risk of heart disease, stroke, death, or Type 2 diabetes. Kentucky ranked sixth in the nation for heart-disease deaths in 2012, according to the federal Centers for Disease Control and Prevention.

"For years everyone has been advised to cut out fats," said lead author Russell de Souza, an assistant professor in McMaster's Department of Clinical Epidemiology and Biostatistics. "Trans fats have no health benefits and pose a significant risk for heart disease, but the case for saturated fat is less clear." He also noted that the researchers are not recommending an increase in saturated fat intake, because evidence does not show that it would benefit health.

Currently, people are recommended to limit saturated fats to less than 10 percent and trans fats to less than one percent of energy. Saturated fats are found in animal products like butter, cows' milk, meat and egg yolks. Trans fats are mostly produced industrially from plant oils to make margarine, snack foods and packaged baked goods.

De Souza and his colleagues analyzed 50 observation studies examining the association between saturated and/or trans fats and health outcomes in adults. The researchers did not find an association between higher saturated fat consumption and death, coronary heart disease, cardiovascular disease, ischemic stroke or type 2 diabetes. Instead, they found that industrial trans fat consumption was associated with a 34 percent increase in death, a 28 percent increase in risk for CHD mortality and a 21 percent increase in risk for CHD.

"Ours and other studies suggest replacing foods high in these fats, such as high-fat or processed meats and donuts, with vegetables oils, nuts and whole grains," de Souza said.

Ky. Rural Health Association meets in Bowling Green Sept. 17-18; major candidates for governor will speak back to back

The Kentucky Rural Health Association's annual conference will be held Sept. 17-18 in Bowling Green, with "a broader range of topics than ever before," KRHA says: "Whether you are a health-care provider, hospital or clinic administrator, community member, rural advocate, student, or simply curious about the rural healthcare landscape, we’ve got you covered."

KRHA says that at the end of the day-and-a-half meeting, attendees will be able to "build an overview of the state of rural health in Kentucky" and "become more skilled advocates for rural health at the local, regional and state levels," as well as explore opportunties for partnerships and collaboration.

A forum for the party nominees for governor will be held after the conclusion of the conference on Friday afternoon. Republican Matt Bevin is scheduled to speak and answer questions from 1:15 to 2 p.m., and Democratic Attorney General Jack Conway is scheduled to do likewise from 2:15 to 3 p.m. Bowling Green is on Central Time. The forum is co-sponsored by the Foundation for a Healthy Kentucky, the Friedell Committee, the Kentucky Academy of Family Physicians, the Kentucky Coalition of Nurse Practitioners & Nurse Midwives, the Kentucky Hospital Association, the Kentucky Medical Association, the Kentucky Primary Care Association and Kentucky Voices for Health. Before lunch, candidates for governor and other statewide offices will have a meet-and-greet session.

The conference and the forum will be held at Western Kentucky University's Knicely Center on Nashville Road, with lodging at the adjacent Staybridge Suites on Campbell Lane and the new Hyatt Place, next to the WKU campus on Center Street (with shuttle service). The registration fees until Sept. 3 are $125 for KRHA members, $200 for non-members and $45 for student members. For the draft agenda, registration form and hotel information, in a PDF, click here.

Ohio Gov. John Kasich, defending his Medicaid expansion as he runs for president, can point to lower-than-expected costs

John Kasich campaigned in Derry, N.H.
(Associated Press photo by Jim Cole)

By Al Cross
Kentucky Health News

Expanded eligibility for Medicaid, an issue in the Kentucky governor's race, is one of the major topics that separate Ohio Gov. John Kasich from his competition in the race for the Republican nomination for president. Like Democratic Gov. Steve Beshear, Kasich used the federal health-reform law to give Medicaid to households with annual income up to 138 percent of the poverty level.

Both states' enrollment of the newly eligible was higher than expected, adding to critics' concern that the expansions are a ticking time bomb for state budgets. States have to start paying 5 percent of the expansion cost in 2017, rising gradually to the law's limit of 10 percent in 2020. Advocates say increased tax revenue from a larger health-care industry will cover the cost, at least for a while.

Last week, Kasich's administration reported that Ohio's total Medicaid spending in the fiscal year that ended June 30 was 7.6 percent less than expected, despite the higher-than-expected enrollment. "Medicaid Director John McCarthy said savings have been achieved through expanded home-based care for seniors, shorter nursing-home stays, expanded managed care, capitated reimbursement policies — pay per patient rather than per patient visit — and other cost-controlling efforts," Catherine Candisky reports for The Columbus Dispatch.

Kentucky officials have pointed to capitated managed care, adopted statewide in November 2011, as the main reason Kentucky's Medicaid expenses have been lower than projected. However, health-care providers complain of slow payment, no payment and unfair treatment by managed-care companies.

Ohio's expansion added more than 500,000 people to the Medicaid rolls, bringing total enrollment to near 3 million. That is about 25 percent of the state's population of 11.6 million. Kentucky's expansion added about 430,000, currently about 400,000. About 1.2 million Kentuckians are on Medicaid, representing about 27 percent of the state's population of 4.4 million.

While Kasich and a few other Republican governors have used the reform law to expand Medicaid, he says that if elected president he would move to replace the law with something better. "The 'repeal' position is essential for Kasich," writes Chrissie Thompson of The Cincinnati Enquirer. "Kasich had to defend his Medicaid move in his first question in the prime-time debate" among top-tier GOP candidates.

"Kasich has insisted he wouldn’t cut back on the expansion of Medicaid to more low-income Americans," Thompson reports. "Instead, he says, he’d want to send the federal money back to states, with more freedoms on how to implement the program." Also, "He’s all but said he’d scrap the controversial (and, thus, delayed) mandate that businesses with at least 50 employees provide coverage for their full-time employees. . . . From there, it gets a little vague, except for Kasich’s clear discomfort with the idea of mandating just about anything." (Read more)

Improving Kentuckians' health will require education, fighting poverty; poor and less educated have poorer health, study shows

By Melissa Patrick
Kentucky Health News

Increased access to insurance is just one part of the equation to improve the health of Kentuckians, improving poverty and increasing education levels are disparities that must also be addressed if Kentucky ever hopes to improve the health of its citizens.

"We believe that health disparities can be eliminated, and that they must be eliminated," say the authors of a recently released report, Money Matters: Health Disparities in the Commonwealth - a Report on Socioeconomic status and health in Kentucky. "The first step towards eliminating health disparities is to understand and monitor where they exist."

The report was released by the Foundation for a Healthy Kentucky and the University of Kentucky College of Public Health.

Using 2011-12 data from the Kentucky Behavioral Risk Factor Surveillance System (the most recent data available), this report looked at the relationship between health, income and education and found that poverty and lower education levels are consistently associated with poorer health.

The data show that people who live in poverty and those with less education are more likely to be smokers. Smoking is a known cause of cancer, heart disease, stroke and other chronic conditions.

In 2011-13, the smoking rate in Kentucky was 28.6 percent, with almost one in three adults smoking. Of this group, almost half of the smokers (45.4 percent) were below poverty, while 20.9 percent were above poverty; and more than four in 10 (44.6 percent) had less than a high school education and about one in 10 (11.9 percent) were college graduates.

Obesity, which contributes to heart disease, stroke, type 2 diabetes and cancer, was also found to be more prevalent among the poor and uneducated.

The report found that 30.8 percent of Kentuckians were obese. Of this group, 38 percent lived below poverty and 30.9 percent lived above poverty; and 33.6 percent of those with less than a high school degree were obese, compared to 25.5 percent of college graduates.

Two-thirds of Kentuckians were considered overweight in the survey, and this was consistent across socioeconomic and education groups.

Poor, less educated Kentuckians in the survey also reported that they were less physically active and that they had increased activity limitations than those who lived above poverty and with more education.

Another health indicator among poor, less educated Kentuckians was that they were more likely to describe their health as fair or poor. Of the 23.1 percent of Kentuckians who described their health as fair or poor, 44.6 percent were below poverty and 17.6 percent were above poverty; and 45.2 percent of them had less than a high school education, while 9.1 percent of them were college graduates.

This finding was also true for people reporting poor physical health and poor mental health.

Of the 16.8 percent of Kentuckians who said they had poor physical health, 36.5 percent lived below poverty and 12.3 percent lived above poverty; and 30.8 percent had less than a high school education, while 7.4 percent were college graduates.

Of the 15.9 percent of Kentuckians who said they had poor mental health, 33.9 percent lived below poverty and 11.1 percent lived above poverty; and 28.2 percent had less than a high school degree, while 7.8 percent were college graduates.

Poorer, less educated people in Kentucky were also found to have increased levels of asthma and diabetes.

While the study also found that poorer Kentuckians have less access to health care, often forgo medical care due to the cost, and are less likely to have health insurance, it must be noted that this data was collected prior to the implementation of the Patient Protection and Affordable Care Act, which has since provided health coverage to more than 500,000 Kentuckians. The percentage of uninsured in Kentucky has dropped to 9 percent, compared to 20.4 percent in 2013, prior to the law's implementation.

That being said, "one-quarter of consumers who buy insurance on their own still have problems being able to afford needed care," according to a Families USA report.

"Simply having health insurance is no guarantee that consumers can afford to pay for health care," the report said. "Health insurance involves different types of costs that consumers must pay out of pocket—ranging from a health plan’s deductible to co-payments at a doctor’s office. These expenses add up, and research has shown that even nominal cost-sharing can deter people from getting needed care."

"Economic opportunity is the cornerstone of getting people jobs and employment. That then requires good education. Those two combined set the stage for people to pay more attention to their own health and the health of their community," Dr. William Hacker, former state health commissioner and current health chair of Shaping Our Appalachian Region, said at a recent advisory council meeting. SOAR is a bipartisan, nonprofit effort to improving the economy of Appalachian Kentucky.

The importance of getting families out of poverty was also noted by Dr. Terry Brooks, executive director of Kentucky Youth Advocates, in response to the 2014 Kids Count report, which ranked Kentucky 32nd in economic well-being.

"Here’s the bottom line from this year’s report: If we as a commonwealth want to get serious about improving the lives of our children, there is one overriding and persistent challenge: poverty," Brooks said. "You can’t talk education or health without talking family economics. And we can begin to tackle persistent poverty only when economic well-being policy stops being political and starts being about the common good."