Nonprofit grades hospitals on patient safety; the 52 ranked in Ky. improved slightly, but the state still ranks relatively low

By Traci Thomas
Kentucky Health News

A nonprofit group that rates hospitals released its patient-safety scores Monday, giving most Kentucky hospitals a 'B' or 'C'. The scores are similar to grades released in June, but the state improved its national rating from 40th to 35th.

The Leapfrog Group, a nonprofit group based in Washington, D.C., evaluated 2,633 hospitals nationwide, including 52 in Kentucky. Most of Kentucky's 129 hospitals were not rated because critical-access hospitals in rural areas don’t have to report their quality measures.

The grades are calculated using 30 publicly available safety-performance measures from the Centers for Medicare & Medicaid Services, the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention and the American Hospital Association’s Annual Survey.

The calculation gave an A to 12 of Kentucky's hospitals, or 21.3 percent, lower than the national average of 31.3 percent. Eighteen each, or 34.6 percent, earned a B or a C. Four hospitals, or 7.7 percent of those reviewed, got a D. That was down from six (11.5 percent) in the spring.

Three of the four Kentucky hospitals that got a D are in Louisville and owned or operated by KentuckyOne Health: Jewish Hospital, Sts. Mary and Elizabeth Hospital and University of Louisville Hospital. A state inspection of University Hospital this year found that shortcomings in nursing had endangered three patients, and nurses and doctors told inspectors that staff shortages put patients at risk.

The data used for the grades go back as far as July 2013 and are no more recent than June 2015.

"KentuckyOne Health said it has implemented programs and best practices to improve quality and safety across its facilities, including at U of L Hospital, which has been fraught with controversy this year," Darla Carter reports for The Courier-Journal.

Company spokesman David McArthur told the newspaper in a statement: "While these Leapfrog Hospital Safety Grades at some of our facilities may not reflect the culture of quality, safety and service instilled in recent years across KentuckyOne Health, we are confident that the commitment of nurses, physicians and employees at all our facilities will guide our improvement and the delivery of quality care."

The other hospital to get a D was Ephraim McDowell Regional Medical Center in Danville. St. Joseph Hospital and St. Joseph East in Lexington, also owned by KentuckyOne, received Cs this fall after getting Ds in the spring.

Among Leapfrog's top safety picks is Pikeville Medical Center, the only Kentucky hospital to get straight As since the rankings began in 2013. The two University of Kentucky hospitals got Bs after getting Cs last spring.

The grades include separate ratings for errors, injuries, accidents and infections. Click here for Kentucky's hospital safety scores.

The Leapfrog Group says its analysis was developed under the guidance of the nation's leading patient-safety experts. The report is peer-reviewed and published in the Journal of Patient Safety.

“In the fast-changing health care landscape, patients should be aware that hospitals are not all equally competent at protecting them from injuries and infections,” Leapfrog President and CEO Leah Binder said in the report. The group tweeted, "No hospital is perfectly safe."

Friedell Committee hears focus should be on prevention programs, community strategies and community partnerships

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Seventy percent of the influence on our health comes from our own behaviors and the environment. So, plans to improve Kentucky's low health status should focus on quality prevention programs, recognizing the importance of community determinants of health, and creating successful community partnerships.

Those were the main arguments from speakers Oct. 25 in Frankfort at the annual meeting of the Friedell Committee for Health, which focused on population health -- defined as "the health outcomes of a group of individuals including the distribution of such outcomes within the group."

Larry Cohen

Larry Cohen, founder and executive director of the Prevention Institute, said we must start demanding quality preventive care, just like we ask for quality health care.

"When people talk about health care, the expectation is for the highest quality, but with prevention we don't always emphasize quality," he said. "We have a lot of tools at our disposal, but they require a different set of strategies, they require a different kind of political will and then they require elements like funding."

Cohen gave several examples of the social and community determinants of health. In Cincinnati, he said, the health department and local hospital tracked asthma rates by location and were able to determine the housing areas that were most affected and the bus routes and truck routes that were causing the most asthma-causing pollutants.

"If we don't change the environment, don't change the norms, we can't change the behavior and the medical conditions are going to be predictable outcomes," Cohen said.

Cohen said genetics influences 20 percent of our health, and health care influences it by 10 percent. Though the environment and our behaviors have a 70 percent influence, but only 3 percent of health resources are spent on prevention.

"In terms of our investment patterns and our prevention strategies, we have a systemic failure in investing in health," he said.

Cohen discussed several new ways to fund preventive health, including collaborative strategies that bring the money saved through prevention programs back to the programs; improved community benefit spending, which is a requirement or non-profit hospitals; and "wellness trusts," which work under the premise that savings from prevention initiatives, like a cigarette tax, is captured and re-invested back into "evidence-informed prevention strategies."

"What we are talking about is a paradigm shift with leadership from Kentucky . . . a different way of working, a different way of thinking, he said.

Community partnerships

Dr. Douglas Scutchfield

Dr. Douglas Scutchfield , the Peter Bosomworth Professor of Health Services Research and Policy at the University of Kentucky, told the group, "There is a paradigm shift. There is a growing realization that controlling the increase in health-care expenditure and improving the health of our nation's population requires major changes in the way we've been doing business."

Scutchfield discussed findings from a study that looked at characteristics of successful relationships between hospitals and health departments.

He said successful partnerships have common threads, including: being built on a basis of trust, with clear, agreed-upon missions and goals that are defined and measurable; having a designated body with a clearly defined charge; and having broad and diversified funding sources.

He said Kentucky has many organizations that have formed successful partnerships with the communities they serve, including Humana and several accredited health departments and their local hospitals.

Patty Dale Tye, a Humana vice-president, said the health-insurance company is working with seven communities, including Louisville, to improve community health by bringing like-minded people together to work on health initiatives specific to their communities, like behavioral health issues, obesity and diabetes and access to healthy foods.

"We can't expect people to be healthy simply by visiting their doctors or using a hospital," she said. "We have to meet them outside of those places, we have to meet them in their communities where they live."

Carrie Conia, accreditation coordinator for the Owensboro-based Green River Health Department, talked about the Green River Regional Health Council, which works to improve access to care, fight obesity and promote healthy lifestyles, offers education about tobacco and substance abuse, and an initiative to help young people make healthy choices.

Lynne Saddler, director of the Northern Kentucky Independent District Health Department, ticked off a long list of its successful community partnerships and said they have worked toward creating an action plan with measurable objectives, like a complete streets project, smoke-free policies, public-housing initiatives and their heroin impact response initiatives.

"Health departments need to change their thinking from controlling and owning the whole process of community health improvement and really think about facilitating and collaborating that," she said.

Judy Mattingly, director of the Franklin County Health Department, pointed out that one of the 10 essential public-health services is mobilizing community partnership. She said partnerships are even more necessary these days because of budget cuts in every aspect of health care, including health departments: "No one agency can do it alone."

State sues failed Kentucky Health Cooperative's former chief executive board and contractors, alleging mismanagement

By Melissa Patrick and Al Cross
Kentucky Health News

The former president and directors of the Kentucky Health Cooperative, created under federal health reform, are facing a lawsuit from the state as liquidator of the failed, not-for-profit health insurer.

“Years of mismanagement by co-op administrators and contractors forced the co-op into liquidation, leaving Kentucky’s citizens and their health-care providers in medically and financially vulnerable positions,” Insurance Commissioner Brian Maynard, liquidator of the cooperative, said in a news release Friday, Oct. 28. “The complaint filed today serves as a step toward justice for the tens of thousands of Kentuckians who have been impacted by the co-op’s failure.”

The suit in Franklin Circuit Court at Frankfort, in the name of deputy liquidator Jeff Gaither, claims gross negligence and breach of contract and fiduciary duties by the co-op’s former contractors and management, including President Janie Miller, Board Chairman Joe Smith and other directors; Beam Partners LLC and its principal, Terry S. Shilling of Atlanta; and CGI Technologies and Solutions.

Janie Miller (Associated Press photo)

The lawsuit says Miller failed to set premiums high enough to keep the co-op solvent, seeks an unspecified amount of damages for her "reckless conduct," and notes that the co-op paid Miller a $50,000 bonus "even as KYHC was losing millions of dollars," and seeks "disgorgement of funds," a legal term for refunding money gained by illegal or unethical actions. Miller was then-Gov. Steve Beshear's first health and family services secretary.

The suit claims CGI failed to provide "adequately trained personnel," did not pay claims timely, overpaid claims and failed to properly process enrollments of policyholders, and should refund the millions of dollars in fees that it collected.

The suit alleges Beam recommended CGI as the co-op's third-party administrator though it lacked adequate experience; recruiting directors without proper backgrounds to oversee a health-insurance company, and failing to "adequately train and orient" them; and failing to "monitor or supervise the performance of the individuals and entities it selected or recommended." It says Shilling was a co-op board member while his company "negotiated a contract under which it was paid hundreds of thousands of dollars."

The suit claims former co-op board chair Joseph E. Smith of Frankfort and other unnamed directors kept premiums "woefully inadequate" though they knew that would make the co-op insolvent, and kept paying bonuses to co-op executives.

It seeks an unspecified amount of damages, including punitive damages, from the directors, Miller and the contractors for their "wanton and reckless conduct," as well as attorneys' fees. The suit was signed by attorney Paul Harnice of the Frankfort office of the Lexington-based firm of Stoll Keenon Ogden.

Kentucky's co-op was established under the Patient Protection and Affordable Care Act to compete with insurance companies and hold down premium costs. It was one of 23 created under the law, but only six remain, according to healthinsurance.org.

Before it closed in October 2015, Kentucky's co-op sold 75 percent of the policies bought through the state health-insurance exchange and covered about 51,000 people through the end of 2015. The co-op said it had attracted business from the sickest population in the state and had to pay more claims than expected.

The co-op said it had turned things around and could have stayed afloat if Congress had provided sufficient "risk corridor" payments to insurers with disproportionately sick policyholders. Republicans inserted limits on those payments in the December 2014 budget deal, and the Obama administration was unable to make up the difference. The co-op, which had a deficit of $50 million in 2014, was expecting a risk-corridor payment of $77 million, but got only $9.7 million.

Click here for a copy of the complaint, with exhibits. Claims made in filing a lawsuit give only one side of a case.

Cost of employer-based health insurance grew more slowly after 2010 reform law, but not for single-person plans in Kentucky

By Melissa Patrick
Kentucky Health News

The growth in premiums and deductibles for employer-based health insurance has slowed since federal health reform was enacted, but workers probably haven't noticed because incomes haven't kept up with the cost of health care, a new study says.

Kentucky Health News graphic, based on data from Commonwealth Fund report

Kentucky families covered through employers spent, on average, 10.4 percent of their incomes on health insurance in 2015, slightly above the national average of 10.1 percent, according to an analysis by The Commonwealth Fund, a New York-based research foundation. In 2006, the national average was 6.4 percent, just under Kentucky's figure a decade earlier, Kentucky's median family income is less than the national average; in 2015, it was $50,000.

"They’re still facing a bigger burden today even though growth has slowed. . . . because wages have remained largely flat over the last few years,” David Radley, co-author of the report, said during a teleconference.

The study looked at about 154 million Americans under 65 who get health insurance through their employers, using data from the Medical Expenditure Panel Survey and the Current Population Survey.

Critics of the law say it has caused higher premiums on employer plans, but Radley said the research shows otherwise. The study found that annual rates of premium growth for single-person plans have slowed in 33 states and the District of Columbia since 2010, compared to earlier years.

But that wasn't so in Kentucky, where single-person premiums grew at a faster rate between 2010-15 than the rest of the nation: 5 percent, compared to 3.8 percent respectively. That put it in the top eight states for increases.

The report also found that after the passage of the law, employee premium contributions for single-person plans grew more slowly in 31 states, including Kentucky.

Again, Kentucky's costs were slightly higher. A single-person premium contribution in Kentucky grew 4.7 percent annually after 2010, compared to 6.4 percent before 2010. The national rates were 4.2 percent and 6.7 percent, respectively.

Family plans and deductibles

Employee premium contributions for family plans after passage of the law grew more slowly in 30 states and the District of Columbia, says the report. In Kentucky, this rate was about the same before and after 2010: 5.5 percent and 5.4 percent, respectively. The national rates were 6.5 percent and 4.8 percent, respectively.

The report also found that average deductible growth in single-person plans slowed in Kentucky and 26 other states since 2010, though deductible growth remained high in 22 states and the District of Columbia. In Kentucky, deductible growth was 7.9 percent since 2010, compared to 12.5 percent before 2010. In 2015, Kentuckians paid an average of $1,543 for their deductibles, compared to $659 in 2006. Click here for the Kentucky data.

The report came as the federal government announced increases averaging close to 25 percent for premiums on its insurance exchange, which serves about 10 million people who don't have employer health coverage. Kentucky's Cabinet for Health and Family Services has said Kentucky's exchange plans are increasing by an average of 20 percent. Most people on the exchange will also get an increase in government subsidies, which will ease the impact.

Sara Collins, lead author of the report, said some exchange premium increases likely stem from the fact that the exchange is a much smaller and newer market than employer-based markets and that they are still working to understand their risk pools.

The Patient Protection and Affordable Care Act has several provisions that affect employer-sponsored coverage, such as requiring larger employers to provide health insurance to full-time employees, allowing parents to cover their children up to age 26, and covering preventive services with no cost-sharing. Early predictions were that these requirements would cause many employers to stop offering health insurance, but they haven't.

"We just have not seen that," Collins said. "There just hasn't been large-scale disruption in the employer group market."

"There has been little change in the number of people with employer-sponsored coverage since the law's passage in 2010," Radley added.

The authors attribute the slowdown in health-insurance premiums and deductibles to the slowdown in health-care costs since the implementation of the reform law. Commonwealth Fund President David Blumenthal said, “It would help if employers designed health plans that help their workers afford timely care. But since employer health insurance costs are driven by overall health-care costs, it is also crucial to implement provider payment reform and quality improvement initiatives that keep health-care costs down while improving patient outcomes.”

Medicaid participants can change their managed-care organization through Dec. 16; there are five to choose from

Kentuckians with Medicaid coverage can switch to a different managed-care organization though Dec. 16. Switching is voluntary and coverage with a newly chosen MCO will start Jan. 1.

Kentuckians can apply for Medicaid benefits at any time during the year through the state Department for Community Based Services. Upon initial enrollment, Medicaid participants must choose a MCO, but have a 90-day window to change for any reason.

After the window closes, Kentucky Medicaid members can change to a new MCO only during the yearly open enrollment period, which started Oct. 24 and runs through Dec. 16. Once a person is enrolled in the new MCO, they have a 90-day window to make a change.

There are a few exceptions to this rule, which fall under "disenrollment for cause," which includes things like poor quality of care, lack of access to services covered under the MCO contract, and lack of specialty providers to deal with the member's health care needs, to name a few. Members must submit a written or oral request for disenrollment to DCBS or the MCO.

Kentucky has five MCOs to choose from: Aetna Better Health of Kentucky, Anthem Blue Cross and Blue Shield Medicaid, Humana-CareSource, Passport Health Plan and WellCare of Kentucky. Click here for more information on each plan. Click here for Medicaid managed-care updates.

The National Committee for Quality Assurance recently rated Passport Health Plan at 4 on a 5-point scale. WellCare was rated 3.5, Aetna, 3; Humana, 2.5; and Anthem, 2. The annual ratings are based on measures of consumer satisfaction, treatment and prevention. Click here for more details on the ratings.

Eligible members can change MCOs by calling 855-446-1245, Monday through Friday from 8 a.m. to 5 p.m. Eastern Time.

Kentucky ranked No. 1 in the percentage of cancer deaths that were related to smoking in 2014

Kentucky has long ranked No. 1 in cancer deaths, and in deaths from lung cancer, so it seems only natural that it rank first in deaths from smoking. It did in a study by the American Cancer Society, published in JAMA Internal Medicine, that ranked every state for percentage of cancer deaths in 2014 that were related to smoking.

In Kentucky, 34 percent of cancer deaths were related to smoking. The other top states were all in the South: Arkansas (33.5 percent), Tennessee (32.9), West Virginia (32.6) and Louisiana (32.6). Then came Alaska (31.4), Missouri (31.3), Alabama (31.3), Oklahoma (31.1) and Nevada (30.9), rounding out the top 10. (Map shows numerical rank and quartile of each state)

The study looked at 12 cancers: acute myeloid leukemia and cancers of the oral cavity and pharynx; esophagus; stomach; colorectum; liver; pancreas; larynx; trachea, lung, and bronchus; cervix uteri; kidney and renal pelvis; and urinary bladder. Among the 167,133 deaths in 2014 from those cancers, 28.6 percent were attributed to smoking.

The study also ranked states by smoking-caused cancer deaths among men (103,609) and women (63,524). Nine of the top 10 states for men and six of the top 10 states for women were in the South. Arkansas led in deaths among men, with 39.5 percent. Utah was the only state under 30 percent, at 21.8. Among women, Kentucky had the highest share, 29 percent. Utah had the lowest, at 11. Only Utah, California and Hawaii were under 20 percent. (Read more)

Feds give UK $19.8 million second-round grant to bring health research into communities in Kentucky and Central Appalachia

By Al Cross and Traci Thomas
Kentucky Health News

A four-year, $19.8 million research grant to the University of Kentucky will bring better health care for people in Kentucky and Central Appalachia, U.S. Sen. Mitch McConnell said at Thursday's announcement of the grant. "It's great news for the entire commonwealth," said McConnell, the Senate majority leader.

The grant is the second multi-year award for UK's Center for Clinical and Translational Science, which was established with another grant in 2011 after years of effort. There are 64 such centers, funded by the National Institutes of Health, which McConnell lobbied for the money. The grants "support innovative solutions to improve the efficiency, quality, and impact of translating scientific discoveries into interventions or applications that improve the health of individuals and communities," a UK news release said.

L-R: CCTS Director Phillip Kern, grant-funded diabetes screener Brittany Martin, U.S. Rep.
Andy Barr, UK Health VP Michael Karpf, President Eli Capilouto, U.S. Sen. Mitch McConnell,
UK Research VP Lisa Cassis, UK College of Medicine Dean Robert DiPaola. (UK photo)

Most but not all of the centers that applied for this round of funding received money, according to Dr. Phillip Kern, director of the center. UK President Eli Capilouto complimented Kern and others who worked on the application but said McConnell was "another reason we got across the finish line."

Capilouto said that the grant positions the university "to recruit the brightest scientific minds of our generation," but the heart of its impact is on communities. McConnell noted that Kentucky has the nation's highest rate of deaths from cancer, and Eastern Kentucky has many great health disparities. The UK center is the translational-science hub for Central Appalachia.

Kern cited several examples of useful research done under the previous grant, including a collaboration that found disruptive behavior and hearing loss among Appalachian children are related.

Brittany Martin, coordinator of the Big Sandy Diabetes Coalition, told how the center had helped her personally screen more than 800 people in five far-eastern counties. She is a graduate of the center's Community Leadership Institute of Kentucky, which provides research and training in health for community leaders.

Dr. Michael Karpf, UK's executive vice president for health affairs, said "Developing new treatments and diagnostics, and training top-notch physicians and researchers who can carry on the processes of discovery" will provide the most advanced care for Kentuckians. "Our focused efforts and investment in translational team science mean we have more clinical trials available to our patients, and we’re able to bring the best and most innovative science to their care," he said.

Part of UK's grant goes to Marshall University in Huntington, W.Va., for work in the Mountain State. Marshall is part of the Appalachian Translational Research Network founded by UK, along with West Virginia University in Morgantown, Ohio University in Athens, The Ohio State University in Columbus, the University of Cincinnati and East Tennessee State University in Johnson City.

Health commissioner leaves political correctness at the door, talks about getting governor to back anti-smoking measures

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. - State health officials didn't shy away from saying that smoking was one of Kentucky's top health issues at a recent meeting about population health, and Health Commissioner Hiram Polk went so far as to say they need to find a way to get Gov. Matt Bevin, who says smoking bans are a local issue, to adjust his policy.

Dr. Hiram Polk

"We've got to find some kind of landmark we can use there that would be acceptable to the governor and get through the legislature," Polk told the Friedell Committee for Health Oct. 25 in Frankfort.

Polk called smoking a "political issue" and said solutions include higher cigarette taxes and enforcement of smoke-free areas. He also said he has been talking to Ben Chandler, the new director of the Foundation for a Healthy Kentucky, about ways to get the governor to adjust his stance on this issue.

"It is really rare for somebody in this position to say publicly that 'I want to try to change the governor's mind'," Al Cross, director of the Institute for Rural Journalism and Community Issues, publisher of Kentucky Health News and Friedell Committee member, told the group as he summarized the day. Cross said the 80-year-old Polk, a noted surgeon, is a "guy who speaks his mind."

Tim Feeley, deputy secretary of the Cabinet for Health and Family Services, noted that Kentucky has some of the highest smoking rates in the nation, along with obesity, cancer and opioid abuse. He called for more smoking and nutrition education.

Drug issues

Polk said since taking office his "time has been overwhelmed with the issues of IV drug abuse." And that after attending many meetings on the topic, "There are no good ideas about what to do with drug addiction."

He said the cabinet is working on three opioid initiatives: one that centers around a "healthy living" early childhood educational program, which he hopes to have set up in at least five school districts by fall 2017; a program to increase access to medication-assisted treatments; and beginning this week, a program involving the state's mobile pharmacy, which will travel around the state upon invitation and share educational literature, pass out free Narcan (naloxone), accept outdated drugs and operate a one-for-one syringe exchange.

There was some question about the state's requirement that syringe exchanges be one for one. Feeley said, "As of right now, Governor Bevin has endorsed the needle exchange on a local-option basis. He has also stated that he is in favor of a one-for-one needle exchange. . . . We want to do a needle exchange that encourages the individuals to come in and to get into treatment. . . . Some of the thought is that a one-to-one exchange is the best way to do that."

Cross said the administration's stance seems to be that only exchanges funded by state grants will have to be a one-for-one exchange. He said this strategy might work to appease the legislators who don't understand that this is a public health program designed to prevent the spread of HIV and hepatitis C. "We'll find out during the General Assembly," he said.

Polk also pointed out the increased health disparities among the state's African American population and those living in the Appalachian region, though he emphasized the problems in Appalachia.

"The situation in Appalachia is just appalling," he said. "I think again, Appalachia is more discriminated against than African Americans. If you look at anything. It needs the most help for everything."

Cross said that while Polk "is not politically correct," this is "largely a good thing" because public officials often "don't say what they believe to be fact and try to avoid confrontation. Hiram Polk is not conflict-averse, and we should be thankful for that."

And as for finding health solutions, Polk boldly reminded those in the room that many health decisions are selfishly motivated.

"We've got conflicting and selfish interests of people all over health care, many of which are represented in this room," he said. The perfect example of this, he said, is the pharmaceutical industry, which successfully lobbied to protect its "massive profits" under the Patient Protection and Affordable Care Act. He also said that the "larcenous nature" of this industry is sure to demand "$1,000 for every single treatment" of the newly developed medication assisted treatment drugs, which the state hopes to promote.

Cross said drug makers argue that their profits finance cutting-edge drug research, but also comprise a powerful lobby that knows how to influence the political system. He said the Kentucky Farm Bureau Federation is likewise a powerful lobby, "which I believe is the primary device by which Kentucky's tobacco heritage remains in control of tobacco policy in this state. . . . If you can change Farm Bureau, you can change the game."

Medicaid boss speaks

Medicaid Commissioner Steve Miller briefly reviewed the governor's proposals for the program and said the cost of the current plan is not sustainable. He said the plan "may not be all the answers . . . [but] what we have been doing, and the way we have been doing it, needs to change." After the meeting, Miller told Cross that state and federal officials have entered into negotiations about it.

Miller told the committee his agency is working to hold Medicaid managed-care organizations accountable to their contracts, but said they haven't changed their behaviors.

Providers still struggle with MCOs paying them on a timely basis, if at all. They also struggle with the administrative burden of dealing with five different MCOs. Scott Lockard, public health director in Clark County, asked if the state had considered contracting with only one MCO. Miller said the state wasn't ready to go that far, but averred, "We don't need to have five. I think we need to have more than two."

Raynor Mullins, professor emeritus at the University of Kentucky College of Dentistry, said it is clearly understood that Kentucky's financial woes are "substantial" and  asked, "When are we going to get serious and start to talk about tax reform?"

Miller said he would leave tax policy to others, but added, "The revenue stream as it exist today is not adequate enough to cover the Medicaid expenditures and other things that need to be done. . . . It is not sustainable as we are doing it today."

DEA investigators say officials purposely hampered attempts to slow rise of opioids, doing the bidding of drug manufacturers

Drug ­Enforcement Administration investigators say attempts to staunch the rise of opioids were derailed by interference from higher ups, Lenny Bernstein and Scott Higham report for The Washington Post. Ten years ago, DEA "began to target wholesale companies that distributed hundreds of millions of highly addictive pills to the corrupt pharmacies and pill mills that illegally sold the drugs for street use," but the industry fought back, and administrators caved to industry pressure, the Post reports. (Post graphic: Opioid cases pursued by DEA)

"Former DEA and Justice Department officials hired by drug companies began pressing for a softer approach," Bernstein and Higham write. "In early 2012, the deputy attorney general summoned the DEA’s diversion chief to an unusual meeting over a case against two major drug companies." Joseph T. Rannazzisi, who ran the diversion office for a decade before he was removed from his position and retired in 2015, told the Post, “That meeting was to chastise me for going after industry, and that’s all that meeting was about.”

Rannazzisi vowed to continue the campaign, Bernstein and Higham write. "But soon officials at DEA headquarters began delaying and blocking enforcement actions, and the number of cases plummeted, according to on-the-record interviews with five former agency supervisors and internal records obtained by The Post."

The number of DEA civil-case filings against distributors, manufacturers, pharmacies and doctors dropped from 131 in fiscal year 2011 to 40 in fiscal year 2014, Bernstein and Higham write. During the same time period, the immediate suspension orders, the DEA’s strongest weapon of enforcement, dropped from 65 to nine. "The slowdown began in 2013 after DEA lawyers started requiring a higher standard of proof before cases could move forward."

"Several DEA officials on the front lines of the opioid war said they could not persuade headquarters to approve their cases at the peak of the epidemic," Bernstein and Higham write. "They said they confronted Clifford Lee Reeves II, a lawyer in charge of approving their cases, to no avail." Jim Geldhof, who was the diversion program manager in the Detroit field office when Reeves took over at DEA headquarters in 2012, told the Post, “It was like he was on their side, not ours. I don’t know what his motive was, but we had people dying. We were in the throes of a major pill epidemic.” (Read more)

Kentucky behavioral health specialist says the state has been 'epicenter' of the nation's addiction epidemic for almost 20 years

Though the United States' addiction problem and overdose deaths has sparked national attention, the epidemic in Kentucky dates back to the late 1990s. Geoff Wilson, a Lexington-based substance abuse counselor, said the No. 1 place to get a prescribed narcotic in the United States between 1998 and 2001 was Martin and Lawrence counties, followed by Pike County and Johnson County. "We've been the epicenter of this catastrophe since 1997 and 1998," he said.

Wilson, a business development director at The Ridge Behavioral Health System in Lexington, made these remarks and more at the close of Baptist Health Paducah's 10th annual symposium on addiction and compulsive orders, Joshua Roberts reports for The Paducah Sun. The symposium saw its largest-ever crowd of 140 participants, most of them health-care professionals or educators. Nearly all said they had known a young adult between the ages of 18 and 30 who died from an overdose.

According to the Kentucky Office of Drug Control Policy, 1,248 people died of drug overdoses last year, up from 1,088 the year before. "We have more deaths by overdose than car wrecks," Wilson said.

"Kentucky's addiction problem -- and the recent spike in overdose fatalities -- has been compounded by the rise of the powerful painkiller fentanyl," Roberts writes. Fentanyl, which is anywhere from 10 to 100 times more potent than heroin, is a selling spot for drug dealers, Wilson told the audience.

"For the drug dealers out there, it kind of makes sense. If I get fentanyl . . . I mix it with heroin, I can spread out the heroin so much further, and I can sell it to a lot larger population," Wilson said.

"Prescribed opiates are nothing new," Roberts writes. "They've been around for decades, but use and abuse has expanded because 'Somewhere along the way our country decided you're just not supposed to experience pain anymore,' Wilson added. The U.S., he said, consumes 95 to 99 percent of the world's hydrocodone and 73 percent of the world's oxycodone. Fentanyl, he added, comes largely from Chinese manufacturers and moves through Mexico into the U.S."

Kentuckians who qualify for tax-subsidized health plans will sign up on HealthCare.gov this year; open enrollment begins Nov. 1

By Melissa Patrick
Kentucky Health News

Kentuckians who qualify for health plans subsidized by tax credits, called Qualified Health Plans, will sign up on HealthCare.gov instead of Kynect during the open enrollment that begins Nov. 1.

Some Kynect advocates have voiced concern that the changeover will be troublesome, but Cabinet for Health and Family Services spokesman Doug Hogan said in an e-mail, "We expect a smooth transition to HealthCare.gov. People should be aware that Kynect is not health insurance, it is a website. This transition changes the web portal people use to enroll."

Hogan said the state has sent letters about the transition to Kentuckians who have previously applied or been enrolled in health coverage through Kynect, to guide them through the process. He said the state will continue to send informational postcards throughout open enrollment, which ends Jan. 31.

"Only about 2 percent of Kentucky’s population purchases a QHP in a given year, so targeting resources to this group and doing it in the final month leading up to open enrollment and continuing through open enrollment is the most effective use of resources," Hogan said.

Hogan said that starting Nov. 1, Kynect's website will offer detailed messages about the transition and directions on when and were to apply for coverage. The HealthCare.gov website also has messages for Kentucky residents.

Where to get answers to your questions

The Kynect call center (855-459-6328) will remain available to help tell Kentuckians where to go for coverage, answer questions, pre-screen for program eligibility, and assist with Medicaid applications. The HealthCare.gov customer service call center (800-318-2596) is also available to help and is open 24 hours a day, seven days a week.

Hogan said insurers are also sending notices to their enrollees about the changes; insurance agents and application assisters have advertising tool kits for their outreach efforts; and agents and assisters have been given lists of their QHP enrollees. Also, social media campaigns, media advertising and other measures have different start times around the state in strategically placed target areas with the highest uninsured rates and QHP eligible populations, he said.

If you qualify for a QHP in 2017, which is a plan that offers a tax credit to help cover out-of-pocket costs, you must sign up for your health insurance through HealthCare.gov this year instead of Kynect, as you have in the past.

"Kentuckians can only get the tax credit, called APTC or Advanced Premium Tax Credit or a Cost Sharing Reduction that helps cover out-of-pocket costs, by enrolling through HealthCare.gov," Hogan said.

Open enrollment for these plans is Nov. 1 through Jan. 31, but to get coverage on Jan. 1, you must enroll by Dec. 15.

Can I preview the 2017 plans and prices?

HealthCare.gov offers a user-friendly tool to preview 2017 plans and prices. Access the tool by clicking on the bright green "Preview 2017 Plans and Prices" button on the HealthCare.gov website and follow the prompts.

To fill in the prompts you will need to know your ZIP code, your county, whether you have enrolled in a 2016 Marketplace plan, the ages and the sex of those in your household, your marriage status, and your expected income. It will also request some other information, including whether you are eligible for health coverage elsewhere, if you are a parent of a child under 19, or if you are pregnant or a tobacco user.

After answering these prompts, the website will tell you what your estimated premium tax credit is if you qualify for one. A tax credit is how much you can save on your premium each month and not the amount of the premium itself.

The next portion of the website tool takes you to your plan choices available based on the information provided. It will ask a few questions to help narrow your choices and will then ask you to choose a bronze, silver or gold plan. After choosing a plan type, it will bring all of the plans in that category up for you to review and choose from. Your exact premium, reduced by the tax credit you qualify for, will be stated when you complete or update your application.

Why aren't there as many choices as last year?

In 59 of the state's 120 counties, residents will have only one health insurance option on the exchange. Anthem Health Plans of Kentucky is the only company offering coverage on the exchange in every county for 2017. CareSource will offer plans in 61 counties, up from 46 in 2016 and Humana Health Plan will offer exchange plans in nine counties, down from 15 in 2016.

Baptist Health Plan, United HealthCare, WellCare and Aetna, which offered plans on the exchange in 2016, will not in 2017. Most have cited unsustainable losses.

"People should know that this transition to HealthCare.gov did not affect plan choice," Hogan said. "All insurers made the same offerings regardless of the enrollment website we selected which is the same as in prior years."

Hogan added, "Cost increases were not driven by the transition to HealthCare.gov." He said premiums on exchange policies are increasing by more than 20 percent.

People whose current insurers are not offering a plan in 2017 on HealthCare.gov will be given more time to choose a plan for 2017 due to a "special enrollment period for loss of minimum essential coverage," Hogan said.

Do we still have Kynectors?

The state has extended contracts with the same organizations that provided Kynectors, which are now called "application assisters," Hogan said. Application assisters work with Kentuckians either in person or over the phone to answer questions or get assistance with the application and enrollment process.

"We are confident our assister agencies will have the ability to provide the same exceptional service," Hogan said. "Every county in Kentucky is served by a contracted organization for in person assistance. Kynectors have a very active outreach program that includes sign up events, advertising, and education opportunities. They will continue to be very active in the communities they serve."

You can find an Application assister in your area by using the "search" function on the Kynect website or by calling Kynect's customer service.

Many Kynectors are still in the process of being trained to help clients on the federal marketplace, so Hogan said there isn't a firm number of participating application assisters for 2017.

What about Medicaid?

The Medicaid program for low-income and disabled people, and its application process, will stay the same. It was moved from Kynect earlier this year.

Medicaid-eligible Kentuckians can apply anytime during the year through Benefind, a one-stop-shop website for public benefits. But if you are already enrolled, you don't need to do anything until your renewal or recertification date.

"If a citizen believes they may be eligible for Medicaid (any type), we would recommend that they apply through Benefind," Hogan said. "This would be the quickest route to receive Medicaid eligibility."

Benefind also has an anonymous pre-screening tool to assist in determining if you are eligible for Medicaid or a QHP.

Consumers may ask, "What happens if I apply for the wrong type of coverage?" Hogan answered, "Consumers cannot apply in the wrong way or place." He said if an application is started in Benefind, but the applicant is over the income limit, the application will be transferred to the federal marketplace and Benefind will send a notification letter to the participant indicating Medicaid eligibility was denied and that the client information was sent to HealthCare.gov.

If a consumer submits an application to HealthCare.gov, it will be entered, but if the applicant is deemed Medicaid-eligible, the application will be transferred to the state for final eligibility determination. If the participant is determined eligible, Benefind will notify the participant. If more information is needed, Benefind will ask the participant for it, indicating the next steps to take.

UK center promotes at-home test for colorectal cancer, reports on efforts to get young women vaccinated for cervical cancer

More people in Appalachian Kentucky die from colorectal cancer than in any other region of the state. A screening project of the Rural Cancer Prevention Center at the University of Kentucky is working to decrease those rates.

Cancer Registry maps show in color Kentucky counties served by the Appalachian Regional Commission,
and rates for invasive cancer and cancer mortality in Appalachian Kentucky and the balance of the state.

In July 2014, the center received a $3.75 million, five-year grant renewal from the federal Centers for Disease Control and Prevention for a colorectal cancer at-home screening prevention project in Central Appalachia and other rural areas. The UK Center is one of 26 CDC-funded Prevention Research Centers in the country.

Tom Collins, associate director of the RCPC, gave an update on its project at a Center for Clinical and Translational Science clinical research update meeting at UK Oct.18. Robin Vanderpool, associate professor in the College of Public Health, discussed the results and successes of its completed cervical-cancer screening project.

Early screening and prevention are key to surviving colorectal cancer. The CDC says that most deaths caused by colorectal cancer could be prevented if everyone over the age of 50 got screened. And if detected early, treatment for colorectal cancer is highly effective.

In 2013, the last year for which data is available, Kentucky ranked first in colon cancer and fourth in colon-cancer deaths, according to the Colon Cancer Prevention Project.

The project's title and motto is "I did FIT." FIT stands for fecal immunochemical test, an at-home test that allows a person to collect a small stool sample in the privacy of their home and mail it in a provided kit to the lab for testing. The FIT test must be done every year.

Since June 2015, the UK center has distributed more than 700 kits, with a 60 percent return rate in the eight-county Kentucky River Health District. Those with a positive test result, about one in six, have been offered a colonoscopy with follow-up; the rest have been invited to be part of the research, which is ongoing.

To help determine the best way to get people to do a yearly test, researchers divided the volunteer participants into two groups: one that gets social media and personal messages about it along with the traditional standard of care and another that gets standard of care alone. A year and a half remains in this portion of the research.

Cervical cancer and the HPV vaccine

Collins said they are trying to build on the success of the UK Center's previous prevention program for cervical cancer prevention and screening, called "1-2-3 Pap."

Prevention Research Center graphic; click on it to view a larger version

This UK center study promoted the human papillomavirus vaccination to prevent cervical cancer in Appalachia, which also has a higher incidence and mortality rate for cervical cancer than the rest of the state.

The three-dose HPV vaccine was approved by the federal government 10 years ago and is recommended for all adolescent girls and boys 11 and 12 years old. It is approved for females between 9 and 26 and is nearly 100 percent effective in preventing pre-cancers and noninvasive cervical cancers caused by two strains of the virus.

Kentucky falls in the bottom 10 states for HPV vaccinations, with 37.5 percent of its girls and 13.3 percent of boys aged 13-17 vaccinated as of 2014.

An earlier study of adult Appalachian women aged 18-26 that were offered the first HPV vaccination free found that 45.1 percent got the first dose, 13.8 percent got the second dose and only 4.5 percent got all three doses. This and other formative research prompted the UK Center to start a two-stage HPV vaccine promotion program for women aged 19-26 in the Kentucky River Health District.

First, researchers launched a marketing campaign to recruit the women in for the first dose. Then, participants were asked to participate in the study, which was designed to promote adherence to doses two and three. The volunteer participants were randomly separated into two groups; one participated in an informational video-based intervention that was made using local people along with the traditional standard of care; the other was offered standard of care alone.

The study found that 43.3 percent of the young women who watched the DVD completed the three-dose HPV vaccine series, while 31.9 percent of the women in the comparison group completed the series.

Vanderpool said the "take-home message" was that women were two and one-half times more likely to complete the series if they watched the DVD.

Since the completion of the study, 18 Kentucky health departments now use the DVD to promote completion of the three-dose HPV series, and it has also been adapted for use in North Carolina and West Virginia.

U.S. Rep. John Yarmuth says Bevin's Medicaid plan won't be approved, should be withdrawn; Bevin aide says call is political

U.S. Rep. John Yarmuth

Democratic U.S. Rep. John Yarmuth of Louisville called on Republican Gov. Matt Bevin to withdraw his proposal to reshape Kentucky's Medicaid program at a news conference Oct. 18 in Frankfort, saying the proposal in its current form will be denied.

Yarmuth said it's clear the Department of Health and Human Services will reject the plan because the agency recently rejected similar changes proposed by other states, Deborah Yetter and Tom Loftus report for The Courier-Journal.

"There is no longer any argument about the outcome of your strategy," Yarmuth told Bevin in a letter. "It will fail."

Yarmuth noted that Ohio's plan was rejected for its premium charges without respect to income and because it would create a large loss of coverage and that parts of Arizona's plan were rejected because of its premium requirements for individuals living below the poverty line, work requirements and its six month lock-out period for non-payment of monthly premiums. He said all of these rejected provisions are in Bevin's plan.

The plan, submitted under a waiver from federal rules that allows demonstration waivers, focuses on "able-bodied adults" who qualify for Medicaid under the expansion of the program to those who earn up to 138 percent of the federal poverty level.

The changes are meant to increase participants engagement in their health care through things like monthly premiums of $1 to $37.50, requirements that those who aren't primary caregivers work or volunteer up to 20 hours a week to keep coverage and "lockouts" of coverage for some who fail to pay.

Yarmuth said federal officials have told him that they will not accept this plan, citing the recent rejections of similar proposals. "There's no chance they are going to approve this waiver," he said.

Bevin has said the state cannot afford to have 1.4 million people on Medicaid. Of those, 440,00 are covered through the expansion. The expanded population is paid in full by the federal government through this year. In 2017, the state will be responsible for 5 percent of the cost, rising in annual steps to the reform law's limit of 10 percent in 2020.

And though Bevin has said he is willing to negotiate, he has also said that he would end the expansion if the federal government does not approve his changes.

Yarmuth implored him not to do that. "We want to make sure that Kentuckians understand exactly what's at stake – 10 percent of the people of this commonwealth who now have coverage are going to lose it," Yarmuth said.

Bevin's press secretary, Amanda Stamper, said in a statement that federal officials have "full authority" to approve Kentucky's waiver and Yarmuth's news conference was politically motivated.

"While Congressman Yarmuth plays politics three weeks before an election, Gov. Bevin and his team have spent several months developing a transformative and financially sustainable Medicaid plan that will actually improve health outcomes for Kentuckians and encourage self-sufficiency," Stamper said. "Gov. Bevin remain committed to working with the Centers for Medicare and Medicaid Services as long as it takes to transform Kentucky's Medicaid program to achieve these vital goals."

Yarmuth acknowledged that Bevin's actions represent what he promised during his election last year, but said he doubted voters believed he would do it, The Courier-Journal reports. A poll taken shortly after the election shows that most Kentuckians did not want the expansion scaled back.

Yarmuth also said if Bevin does make good on his promise to take away health coverage from 440,000 Kentuckians, he should "pay some political price. ... But that's not why we're here. We're here because our citizens will pay the price."

Cancer, and death from it, rose in rural Appalachia from 1969 to 2011; Appalachian Kentucky's cancer-death rate was 36% higher

Appalachian Regional Commission service area

From 1969 to 2011 the cancer death rate in rural Appalachia went from the nation's lowest to its highest, says a study at the University of Virginia researchers, published in the Journal of Rural Health. The study, which used data from 23,565 men and 37,847 women first studied in 1999, found that cancer mortality rates were higher in every rural Appalachian area—except in Maryland—than in urban areas.

From 1969 to 2011, "Cancer incidence declined in every region of the country except rural Appalachia, where it increased," Josh Barney reports for UVA Today. "In the rural Appalachian areas of Kentucky, mortality rates were 36 percent higher. People in Appalachia are more likely to die within three to five years of their cancer diagnoses than people in urban areas outside Appalachia."

One possibility for higher rural cancer death rates is a lack of screening, researchers said. Among people 50 or older living in Appalachia, 16.2 percent of rural residents received a fecal occult blood test in the past year, compared to 22 percent in urban areas. Also, 28.2 percent of rural residents had a colonoscopy in the past five years, compared to 35.2 percent in urban areas.

Researchers said other factors affecting rural areas include a lack of health care, transportation hurdles to seek care, higher poverty, smoking and obesity rates and a rural attitude of fiercely independent people who refuse to seek care.

Study: Ky. kids have more access to oral health care, but still have poor outcomes; 1/2 in Appalachia have untreated cavities

By Melissa Patrick and Traci Thomas
Kentucky Health News

The oral health of Kentucky's school children is getting worse, even though access to oral health care is better now than it was 15 years ago, says a study by Delta Dental of Kentucky and Kentucky Youth Advocates.

The report, "Making Smiles Happen: 2016 Oral Health Study of Kentucky's Youth," is the first oral health study of Kentucky's children since 2001, and was presented to Kentucky lawmakers Wednesday at the Oct. 19 Interim Joint Committee on Health and Welfare.

"What leaps out in the report are two big issues," said Dr. Terry Brooks, executive director of Kentucky Youth Advocates. "One is the paradox that more kids have coverage and yet outcomes are worse and the second is that we have factors that kids can't control -- where they live, the color of their skin, how much money their parents make -- and those are real determinants on the state of kids mouths. None of those are easily solved, but they are challenges that we have to tackle."

Delta Dental of Kentucky and Kentucky Youth Advocates study.
(Lexington Herald-Leader map)

Researchers worked with the University of Louisville's School of Dentistry to analyze the mouths of 3rd and 6th graders across the state. The study also asked parents about family oral health history, resulting in the collection of data for over 2,000 students.

The report had four key findings.

First, it found that more 3rd and 6th graders are in need of early or urgent dental care since 2001, rising to 49 percent in 2016 from 32 percent in 2001. It noted that Hispanic or Latino students are "significantly less likely" to have dental insurance than their peers and that children who live in the Appalachian region have the greatest need for urgent dental care, 20 percent compared to 8 percent overall.

Another key finding was that two out of five 3rd and 6th graders have untreated cavities. This measure was also "significantly greater" in the Appalachian region, where more than half of the children in the study had untreated cavities.

"We know in a very pragmatic way that a person with a toothache is probably not paying attention to their multiplication tables at school, so oral health is a significant issue for children in Kentucky," Brooks said.

And despite a 14 percent increase in the number of 3rd and 6th graders with dental sealants on at least one permanent molar between 2001 and 2016, more than 50 percent of the children in the study didn't have them. African-American children in the study were the most likely to not have any sealants.

It also found the 3rd and 6th graders eligible for free or reduced lunch (more than half of students in the study) were more likely to have recently experienced a toothache, have visited a dentist more than a year ago, have untreated decay or be in need of urgent dental care.

The report points out that "there was no significant differences in the presence of tooth decay by race/ethnicity, giving further evidence that socioeconomic status is in the strongest determinant of a child's oral health status."

Delta Dental President Clifford Maesaka said the report recommends the data be used to make a comprehensive statewide plan and that regional coalitions should be formed to find local solutions. The report also recommends school-based sealant programs, oral health literacy campaigns and points out that the state should continue to gather data.

"We need a plan," Maesaka said. "If we don't recognize the need for preventive and diagnostic care in our kids, we are probably not going to make it a priority." He added, "We need our parents, our school administrators, our legislators, everybody to recognize that the mouth is part of the body and things that go on in the mouth have an effect on the rest of the body and vice-versa." If the message can be conveyed, "We will have a better chance of succeeding."

Kentuckians can submit comments about Gov. Matt Bevin's Medicaid plan until federal officials render a final decision

The 30-day federal public comment period for Gov. Matt Bevin's new Medicaid plan ended Oct. 8, but the U.S. Department of Health and Human Services says it will continue to accept comments until it renders a final decision.

"While our rules do not provide for formally extending the federal comment period, as a matter of practice CMS has generally reviewed and considered all public comments received prior to rendering a final decision," Eliot Fishman, director of the state demonstrations group at the Centers for Medicare and Medicaid Services, wrote in a letter dated Oct. 19 to Kentucky Insurance Commissioner Stephen P. Miller.

The changes in Bevin's proposed Medicaid plan largely target "able bodied adults" who qualify for Medicaid under the expansion of the program to those who earn up to 138 percent of the federal poverty level. The governor's new plan is designed to encourage participants to have what he calls "skin in the game" through things like monthly premiums, health savings accounts and work and volunteer requirements for those who aren't primary caregivers. Critics of the plan say it is too complicated and creates barriers to health care.

Bevin has said the current Medicaid plan is unsustainable and that the new plan will save an estimated $2.2 billion over the five-year waiver period, of which the state portion would be $331 million. The federal government is paying the full cost of Medicaid expansion through this year; next year the state will start paying 5 percent, rising in annual steps to the law's limit of 10 percent in 2020.

Nearly 1,800 comments were submitted by the Oct. 8 deadline and the vast majority of them opposed it. The Kentucky Center for Economic Policy, after removing repeated comments under the same names and removing blank comments and those not related to the issue, counted 1,643 individual comments. Of those, they found 90.1 percent were "unfavorable," 8.4 percent were "favorable" and 1.5 percent were "mixed."

Fishman says it will take time to "carefully consider" the "large volume" of public comments. He also added that they are "prepared to continue our dialogue for as long as it takes to find a solution that continues progress for the people of Kentucky."

In a statement made in response to U.S. Rep. John Yarmuth's call for the governor to withdraw his proposal  since similar request from Arizona and Ohio were rejected, Bevin press secretary Amanda Stamper said that the governor was committed to work with the federal government "as long as it takes to transform Kentucky's Medicaid program to achieve these vital goals." Bevin has said that if his plan is not approved, he will not continue the expansion.

Click here to read the proposal. Click here to submit comments. 

Pikeville Medical Center hires 3,000th employee

Pikeville Medical Center (Photo: sourcelync.net)

Pikeville Medical Center said it reached a milestone Monday when it welcomed its 3,000th employee: information systems project manager Judy Lawson.

The center is the region's largest employer and has added 930 jobs this year, according to a report in Pikeville's Appalachian News-Express.

The report cites a $48 million boon to the local economy from the employment boom.

"With coal jobs disappearing at an alarming rate, our region depends on PMC to contribute to our local economy," Juanita Deskins, chief operating officer, told the newspaper.

"We are seeing patients come from further distances than ever before," said President and CEO Walter E. May, who led the facility's transformation from Pikeville Methodist Hospital. "People in our region recognize that PMC is providing quality healthcare closer to home. We will continue increasing our number of employees to meet the demand for our services."

Paducah Sun editor calls for higher cigarette tax in Kentucky

The executive editor of a West Kentucky newspaper known for its conservative editorials is taking a stand against cigarette taxes, but not in the way you might expect.

In a Sunday column, Steve Wilson of The Paducah Sun lambasted the state's low cigarette tax of 60 cents per pack.

"The average tax in all states is now $1.65 a pack. The tax in neighboring Illinois is $1.98. New York has the nation's highest at $4.35," Wilson writes. "With a tax so much less, Kentucky is not doing right by its citizens in terms of revenue, public health and health-care costs."

Noting that Kentucky has the second-highest smoking rate in the country, 26.5 percent, Wilson suggests that a higher cigarette tax would generate greater revenue for the state and would spark a decline in smoking.

"If people have to pay more for cigarettes, they are less likely to buy them. That's especially true for younger smokers who have lower incomes and are less addicted. And when people smoke less, the benefits to their health and the state's health care costs are huge," he says.

Wilson cites research indicating that health-care costs directly related to smoking in Kentucky are nearly $2 billion a year. He says the state's annual Medicaid costs related to smoking are almost $600 million and paid by taxpayers.

The state set up a Blue Ribbon Commission on Tax Reform in 2012. It spent nearly a year evaluating Kentucky's tax policies and recommended a 40-cent raise, to $1 a pack, which would have brought the state an extra $120 million a year, but the General Assembly didn't bite. Wilson advocates passing that 40-cent increase now and committing a portion of the revenue to smoking-cessation programs.

"Given the staunch anti-tax attitude of the legislature and governor, an increase of any amount is a long shot in the next session," he writes. "It's so much easier for the lawmakers to do nothing and proudly say they stand firm against all tax increases. What they don't say is that such a low tax helps maintain a high rate of smoking, the nation's highest rate of smoking illness and ever-increasing medical bills pushed on the backs of taxpayers."

90% of public comments opposed Bevin's Medicaid plan, but some tell feds that Ky. voted for him to get rid of Obamacare

By Melissa Patrick
Kentucky Health News

Nearly 1,750 Kentuckians submitted comments about Gov. Matt Bevin's plan for Medicaid during the federal public comment period that ended Oct. 8 and the vast majority of them opposed it.

Source of data and chart: Kentucky Center for Economic Policy

The Kentucky Center for Economic Policy, after removing repeated comments submitted over the same names, and the responses that were left blank or were not related to the issue, counted 1,643 individual comments. Of those, they found 90.1 percent were "unfavorable," 8.4 percent were "favorable" and 1.5 percent were "mixed," according to KCEP's KY Policy Blog. These findings were similar to a cursory analysis by Kentucky Health News.

To put this in perspective, Ohio and Arizona, the last two state to have Medicaid waivers considered by the U.S. Department of  Health and Human Services, only drew 103 and 97 comments, respectively.

In response to KCEP's analysis, Bevin' spokeswoman Amanda Stamper told Louisville's WFPL that "Gov. Bevin campaigned on reforming Medicaid expansion and was shown overwhelming support by Kentucky voters who elected him to do just that." However, a poll taken shortly after the election showed most Kentuckians did not want the expansion scaled back, as Bevin wants to do.

The governor's plan focuses on able-bodied adults who qualify for Medicaid under the expansion of the program to those who earn up to 138 percent of the federal poverty level. The new plan is designed to encourage participants to have what Bevin calls "skin in the game" through premiums and a higher level of involvement in their care.

Bevin has said the state cannot afford to have 1.32 million people, nearly 30 percent of Kentucky's estimated population, on Medicaid. About 430,000 are covered through the expansion.

The proposal expects to save taxpayers $2.2 billion over the five-year waiver period by reducing enrollment in the program, but only $331 million of that would be state tax money, because the federal government covers the bulk of Medicaid costs. The expansion population is paid for through 2016, but next year the state begins paying 5 percent of the costs, rising in annual steps to the reform law's limit of 10 percent in 2020.

Bevin has said that if federal officials don't approve this proposal, he would end the expansion, but has said he is willing to negotiate.

The plan is called Kentucky HEALTH, standing for Helping to Engage and Achieve Long-Term Health. It seeks a waiver from federal rules, under a section of law allowing demonstration waivers.

Commenters tell personal stories

Many of the unfavorable comments came from Kentuckians who told personal stories about how Medicaid expansion had benefited them, their loved ones and their neighbors.

"I have never used Medicaid coverage, but I have seen both children and the elderly in my community utilize the services. The residents of Kentucky deserve healthy neighbors and I'm willing to use my taxes to do so," said one comment. (#224665)

Health-care professionals also chimed in with how Medicaid expansion had helped their patients.

"I'm a physician. It's greatly reduced the stress of my patients to have comprehensive coverage, which has thus improved their health: lower blood pressures, better medication adherence, better follow up," said one. (#224169)

Many pleaded with Bevin to not make good on his promise to get rid of the expansion if his plan is not approved.

"Expanded Medicaid is the only reason some of us can see a dentist; it's the only reason we can get a check up, birth control, an antibiotic for a sickness. The expansion made it so that even male members could be covered. Please don't take it away!" one commenter said. (#224745)

Other comments suggested that the plan has political motives.

"For many Kentuckians, Medicaid is the difference between life and death. Holding the health of our citizens hostage for purely political reasons is vicious and despicable, since the people on Medicaid for the most part have no other recourse," said one comment. (#224317)

Many unfavorable comments pointed out specific issues with the plan, including: premiums, other costs, work and volunteer requirements, the lock-out for non-payment, the administrative complexity of the proposed program, removal of automatic renewal, removal of non-emergency medical transportation, the removal of retroactive eligibility, and the loss of dental and vision in the base plan, to name a few.

"The complexity of the program creates unnecessary barriers for individuals to maintain health insurance coverage and manage the benefits. The waiver includes maintenance of a health savings account, health rewards accounts in addition to work, volunteer and health education requirements. This creates a very confusing system with multiple barriers to keeping coverage. that needs to be navigated. The purpose of an 1115 Waiver is to improve access to health care, not create roadblocks," said one comment. (#219253)

Many of the comments also voiced concerns about the removal of dental benefits. The new plan requires participants to earn dental benefits through a rewards program.

M. Raynor Mullins, professor emeritus at the University of Kentucky College of Dentistry, noted in his personal comments that it is well-documented that Kentuckians' access to dental care has improved since the implementation of Medicaid expansion. He said the plan "includes no supporting dental science or detailed dental or cost information or a solid rationale for the dental design and benefit changes," though such information is "readily available."

Mullins questions whether HHS should approve a plan that, in his words, would increase state dental expenses, remove an important health benefit from more than 400,000 Kentuckians, negatively affect rural economies, reduce dental access and ignores the inter-relationship between oral health, diabetes, obesity and heart disease.

Many national and state organizations submitted detailed comments opposing the proposal, including Save Kentucky Healthcare, founded by former Gov. Steve Beshear, who expanded Medicaid. It said that despite Bevin's claims that the expansion is not affordable, "numerous studies show that Medicaid expansion is financially sustainable, and is in fact beneficial both for the state budget and the Kentucky economy as a whole." It also pointed out that most of the savings in the new plan will come from a reduction in enrollment.

HHS's consideration of this waiver is also important to other states.

The policy director of Alabama Arise, a health-advocacy group, wrote that Southern states look to Kentucky as a "beacon for the region," considering it "one of the great hopes of the South for its highly successful Medicaid expansion." And said that if HHS approves this waiver it "would be a backward step not only for Kentuckians but for all Southerners . . . and would send a clear message to reluctant but interested states not to move boldly and affirmatively but to hedge and whittle away the most meaningful provisions of expansion." (#225401)

Fewer than 10 percent of the comments supported the plan

Many of the 8.4 percent of comments in favor of the plan reiterated the governor's stance that the state cannot afford Medicaid as it currently exist; that "able-bodied" Kentuckians need some some "skin in the game," that the plan would promotes self-sufficiency by "helping those who help themselves;" that it would discourage people from taking advantage of the system, and increase a person's dignity by allowing them to pay something for their health care.

"I support Governor Bevin's plan to replace the expensive and one-size-fits-all Obamacare expansion with a plan that requires personal responsibility and meets the unique needs of Kentucky," one commenter said. "I, as a Kentucky taxpayer, expect able-bodied adults to work or volunteer in order to receive taxpayer funded health care and that it should be transitional coverage, not permanent." (#222221)

At least one person told HHS that Bevin was elected to get rid of Obamacare. "Please pass Gov. Bevin's plan and do away with Obama's plan. Plain and simple, this is one of the things we elected you for," they wrote. (#222785)

KCEP noted that only three organizations wrote in support of the waiver, including: Health Management Systems, Inc.; St. Elizabeth Healthcare; and the Kentucky Chapter of the Association of American Physicians and Surgeons, which is skeptical of government involvement in health care.

KCEP said, "The waiver would not likely save the money it claims, would cover fewer people, and would roll back the historic health care gains we’ve made as a commonwealth. As negotiations begin between officials from Kentucky and Washington, the outpouring of concern should be a key factor to consider."

One comment suggested that Kentucky's current Medicaid plan should be allowed to develop for five years before any changes are made, just like the five year demonstration waiver will require if approved.

"Shouldn't the massive change we made to our Medicaid program in January 2014 be allowed to be evaluated for effectiveness, efficiencies, and health outcomes for at least as long as CMS would consider allowing Governor Bevin's proposal?" said one comment, in part. (#222385) CMS stands for the Centers for Medicare and Medicaid Services.

Information for this story was also gathered by Traci Thomas of the University of Kentucky. Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in UK's School of Journalism and Media, with support from the Foundation for a Healthy Kentucky.

National Drug Take-Back Day is Oct. 22; Ky. has 194 prescription drop boxes and many State Police posts will participate

Kentuckians are encouraged to turn in any unused or expired prescription drugs Saturday, Oct. 22, from 10 a.m. to 2 p.m. as part of National Drug Take-Back. The service is free and anonymous.

There are now 194 prescription drop boxes available across Kentucky in 116 counties, with more being added daily, according to the state Office of Drug Control Policy. Click here to find a prescription drug disposal location nearest you. In addition, many Kentucky State Police posts will be collecting unused and expired drugs.

"The goal of this effort is to reduce the volume of drugs that could end up on the streets and then used illegally," says the ODCP website.

National Drug Take Back Day: Kentucky annual collection totals in pounds

In all, Kentucky has collected a total of 59,719 pounds of unused and/or unwanted prescription medications at all Drug Take Back events and locations since October 2011, according to ODCP.

For more information about the Take-Back program, visit www.dea.gov or visit www.odcp.ky.gov for updated collection sites near you.