With swim season upon us, here are water-safety tips; drowning is the top cause of accidental death among young children

Photo: cdc.gov

Summer fun often includes heading to the swimming pool or lake, but it's important to remember that all water activities come with a risk of drowning.

The federal Centers for Disease Control and Prevention reports that every day, about 10 people die from unintentional drowning. Of these, two are children under 15 and most are between 1 and 4.

That doesn't mean you shouldn't enjoy the water, it just means you need to take some safety precautions and stay vigilant, experts advise.

The American Academy of Pediatrics recommends swimming lessons for most children 4 and older because that is when they are developmentally ready to learn to swim. The academy once advised against swimming lessons before age 4, but has has relaxed that recommendation.

Why learn to swim? “Most children are around water in some form, whether it’s a pool, a river, a pond, a lake or the ocean, so learning to swim isn’t just for fun. It’s also important for safety,” says K.J. Hales, author of a book about children and swimming. “For some children, the idea of getting in the water and trying to swim can be a bit frightening,” Hales says. “But with the proper positive reinforcement, they can overcome their fears and discover just how much fun swimming can be.” 

The pediatricians' academy cautions that "swimming lessons will not provide 'drown-proofing' for children of any age" and notes that swimming lessons are just one part of a preventive strategy to keep children safe in or near the water.

The academy offers several water- and pool-safety tips for parents and caregivers, including:

• Never leave children alone or in or near the water, even for a moment. This includes bathtubs, pools, spas,wading pools, or near irrigation ditches or standing water.
• Less experienced swimmers and children under 5 should have an adult, preferably one who knows how to swim and perform CPR, within arm's reach of the child.
• Don't leave a child in or near the water under the care of another young child.
• Never swim alone. Always swim with a buddy, even at a public pool or a lifeguarded beach.
• Designate a "water watcher" when swimming.
• Because drowning can be quick and quiet, the water watcher should pay constant attention and be undistracted while supervising children, even if lifeguards are present.

Pool safety tips:

• If a child is missing, look for him or her in the pool or spa first.
• Install a fence at least 4 feet high around all four sides of the pool.
• Make sure pool gates open out from the pool, and self-close and self-latch at a height children can't reach. Consider alarms on the gate, or underwater alarms as an added layer of protection.
• If the house serves as the fourth side of the pool fence, install an alarm on the exit door to the yard and pool. As an added protection, install window guards on windows facing the pool.
• Remember, some drowning victims have used pet doors to gain access to the pool.
• Keep rescue equipment, a shepherd's hook, a life preserver, a first aid kit and a portable telephone, near the pool. Choose rescue equipment made of fiberglass or other materials that do not conduct electricity.
• "Floaties" and other inflatable swimming aids are not substitutes for approved life jackets and often offer parents a false sense of security.
• Do not use a pool or spa if there are missing drain covers, since drains cause suction that can trap a swimmer under water. Replace old drains with anti-entrapment drain covers or other similar systems.
• Large, inflatable above-ground pools can be dangerous and need to be surrounded by an appropriate fence. Also, remove access ladders and any structures that provide easy access to the pool when not in use. Children have also fallen in these pools simply by leaning on them.
• Share safety instructions with family, friends and neighbors.

2/3 of wrecks that kill children occur on rural roads

New York Times photo

Unintentional injury is the most common cause of death in children under the age of 15; car wrecks are the most common cause of unintentional injury; and rural roads were the most deadly: 67 percent of deaths among children occurred on roads classified as rural by the Federal Highway Administration. Possible culprits include poor lighting, distance to trauma centers and urban residents’ lack of familiarity with rural roads.

Between 2010 and 2014, 2,885 children died in car wrecks nationwide, an average of 11 kids per week, Nicholas Bakalar writes in The New York Times. That figure does not include pedestrians, those who died in motorcycle or bicycle wrecks or those who died riding in an unenclosed cargo area or trailer. "Most of the children who died were not wearing seat belts — nationwide, 43 percent were unrestrained or improperly restrained. Another 15 percent were sitting inappropriately in the front seat, and 13 percent were riding in cars driven by somebody under the influence of alcohol," Bakalar notes.

Researchers at Brigham and Women’s Hospital in Boston and at the University of Texas Southwestern Medical Center in Dallas carried out this research, which was published in The Journal of Pediatrics.

Researchers also found significant variations in children’s deaths from state to state, Bakalar writes. In New Hampshire, all of the five children who died during the study period were properly restrained. In Mississippi, however, 56 of the 99 who died were not wearing seat belts, or weren't wearing them properly. There were 0.25 deaths per 100,000 children in Massachusetts, compared with 3.23 per 100,000 in Mississippi.

A 2005 study published in Injury Prevention found that rural roads have an overall higher percentage of fatal wrecks than do urban roads: 0.9 percent of wrecks on rural roads are fatal, while only 0.2 percent are fatal in urban areas.

Nelson County starting syringe exchange on one-for-one basis

Requiring "a clean needle for every dirty one . . . isn't the best practice to reduce the spread of blood-borne pathogens such as HIV and hepatitis C" through a syringe exchange, "but it's the one the Nelson County Health Department will adopt for its exchange, which will begin in July," Randy Patrick writes for The Kentucky Standard in Bardstown.

"When addicts first come in, they won't have to bring dirty needles, but for subsequent visits, they will," because that's what the administration of Gov. Matt Bevin requires in return for funding of a syringe exchange, and County Judge-Executive Dean Watts said that was the intent of the county Fiscal Court when it approved the exchange, Patrick reports.

Health officials in Louisville and Lexington do not follow the one-for-one rule and recommend against it. "All it does is encourage the use of sharing dirty needles," Kevin Hall, communicaitons director for the Lexington-Fayette County Health Department, told Patrick.

The exchange will be the first in the six-county Lincoln Trail District Health Department, which also includes Meade, Hardin, LaRue, Marion and Washington counties. None of the district's counties are among the 54 that the federal Centers for Disease Control and Prevention considers most at risk for an HIV or hepatitis outbreak among intravenous drug users. Breckinridge and Grayson counties, which were once part of the district department, are on that list.

Misconception that skin color determines who will get skin cancer is dangerous, medical experts say

Melanoma is often found in hard to see places that
are never exposed to the sun. goldinskin.com

The misconception that people with darker skin are protected from skin cancer is dangerous, says a Rush University Medical Center news release.

While skin cancer rates are higher among white people, blacks, Hispanics and Asians are also at risk of getting a melanoma, which is often caused by genetics and not sun exposure. Melanomas are the most common kind of skin cancer and also the deadliest.

Dr. Arthur Rhodes, the director of the Rush Melanoma Surveillance Clinic, explained in the release that only 10 to 15 percent of melanomas are caused by excessive sun exposure, typically in heavily freckled and sun-damaged skin.

“The misconception that the sun is responsible for all cases of melanoma leads to lower survival rates because of delayed diagnosis, particularly among people of color,” he said.

Sidney Brown, a black man whom Rhodes diagnosed and treated for a melanoma 10 years ago, was one of those people who didn't think African Americans got skin cancer.

Brown said he thought the mole on his nose was just an annoying pimple and never considered that it could be skin cancer, because, he thought, “skin cancer is something white people get.” This misconception nearly cost Brown his life.

Rhodes "explained that once a mole starts growing up, it is also spreading cancer cells down through the body. That can be too late for many, but catching mine in time saved my life,” Brown said in the release.

A 2016 American Academy of Dermatology study, “Racial Disparities in Melanoma Survival,” found that while melanoma incidence is higher in whites, death rates are relatively higher among people of color, says the release.

“Far too often, black, Hispanic, and Asian patients with melanoma cancer tell us they believed that melanoma was only a danger for sun-seeking whites,” says the report. “But anyone – regardless of skin color – may develop melanoma, in both sun-exposed and sun-protected sites. Not noticing or ignoring a new or changing mole in a sun-protected site can be fatal.”

"While less common than other types of skin cancer, melanomas are deadlier, because the malignant cells can spread even though the tumor is relatively small and not bleeding or causing pain or itching," the release says. "This capacity to metastasize underlies the importance of early detection, especially among people of color."

The release notes that some of the most aggressive forms of melanoma may occur in areas of the body that receive little or no sunlight and often occur in difficult-to-examine locations.

“Early diagnosis results in a cure, while delayed diagnosis may be deadly,” Rhodes warns. “Half of all melanomas in non-whites occur on the palms of the hands, soles of the feet, nailbeds, mucous membranes, perianal area, genitalia, and other areas that are not exposed to the sun, areas that are difficult-to-self-examine and commonly ignored.”

Rhodes recommends that everyone should do a monthly full-body self-examination for the presence of new moles, or for any changes to existing moles, including size, shape or color.

Brown has become an advocate for counseling friends and family to pay closer attention to their skin.

"Dark-skinned people think it's nothing," Brown said. "A lot of times we get moles, and we don't think anything about it. Don't accept that it can't be something; go see what it is. Don't say 'Eh, (melanoma is) something that white people get.'"

American Academy of Pediatrics says children under the age of 1 should not be given fruit juice

Children who are less than a year old should not drink fruit juice because it offers them no nutritional benefit, according to new guidelines from the American Academy of Pediatrics.

“Parents may perceive fruit juice as healthy, but it is not a good substitute for fresh fruit and just packs in more sugar and calories,” said Dr. Melvin B. Heyman, co-author of the statement. “Small amounts in moderation are fine for older kids, but are absolutely unnecessary for children under 1.”

The statement, published in the journal Pediatrics, says the change was prompted by the rising rates of childhood obesity and concerns about dental health. The previous recommendation was no fruit juice under the age of 6 months.

The new recommendations for each age group are:

• Children ages 1 to 3 should be limited to four ounces, or 1/2 cup, per day
• Children 4 to 6 can have four to six ounces daily
• Children and teens 7 to 18 should have no more than eight ounces, or 1 cup, per day

The statement also suggests:

• Toddlers should not be given juice at bedtime.
• Toddlers should not be given juice from bottles or sippy cups that allow them to sip on juice throughout the day. This constant exposure can cause tooth decay.
• Children should eat whole fruits.
• Unpasteurized juice is not recommended for children of any age.
• If your child takes any medication, make sure grapefruit juice will not interfere with it. 
• Fruit juice is not recommended to treat dehydration or diarrhea.

Dr. Nikki Stone, associate professor of dentistry at the University of Kentucky College of Dentistry, created a "Drink Pyramid" graphic to educate children about healthy drinking habits that reminds parents and children that juice should only be consumed once a day.

“We know that excessive fruit juice can lead to excessive weight gain and tooth decay,” said co-author Dr. Steven A. Abrams. “Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet.”

Tick season is expected to be more dangerous this year; here are lots of tips to keep you protected

Warm weather and outdoor activities go hand in hand, but it also mean tick season is upon us -- and it's expected to be a bad one this year because the winter was so mild. Tick season in Kentucky runs through August.

Mosquito Squad of Louisville graphic; click on it to see a larger version

The lone star tick and the American dog tick are the most common ticks in Kentucky, and are commonly found in wooded or grassy areas.

The dog tick can transmit Rocky Mountain spotted fever, which begins with a sudden onset of fever and headache two to 14 days after being bitten. Other symptoms can include nausea, muscle pain, lack of appetite and a rash that occurs two to five days after the fever. RMSF can be fatal in the first eight days of symptoms if not treated correctly, according to the Centers for Disease Control and Prevention.

The lone star tick is the main carrier of erlichiosis, which causes fever, headache, chills and muscle pain about one to two weeks after being bitten. It is an aggressive biter, and saliva from its bite can cause painful, itchy areas.

The deer or black legged tick is less common in Kentucky, but it is the one that is known to transmit Lyme disease and Powassan virus.

Symptoms of Lyme disease can range from mild to severe, and include fever, headache, fatigue and a skin rash. If left untreated, the infection can spread to joints, the heart or the nervous system. It is most prevalent in the Northeast, Mid-Atlantic and Upper Midwestern states. The CDC estimates there are 300,000 Lyme disease infections each year. "If a tick is attached to your skin for less than 24 hours your chance of getting Lyme disease is extremely small," says the CDC.

While Powassan virus is most common in the Northeast and the Great Lakes region, it's important to be aware of this virus, especially if you are traveling to these areas, because it can cause encephalitis, or swelling of the brain, and can be deadly. It is also dangerous because it can be transferred from a tick to a human within the first 15 minutes of attachment.

The CDC reports that about 75 cases of Powassan virus have been reported in the U.S. over the past 10 years. Some symptoms of Powasan virus infection are fever, headache, vomiting, weakness, confusion, seizures and memory loss.

The Mosquito Squad of Louisville blog says that 10 percent of people the infected with this virus who get encephalitis will die, "and there is no treatment. Only the symptoms are treatable. Fifty percent of those that survive will have permanent neurological damage of some kind."

Removing ticks: A popular social-media video advises dousing ticks in peppermint oil to get them to pull away from the skin for easy removal. Almost half a million viewers have shared the post, but experts say this is one of the worst things you can do, Caroline Picard reports for Country Living.

"Ticks carry all sorts of diseases," entomologist Dr. Neeta Connally recently told KFGO Radio in Fargo, N.D. "Those are actually salivated into the body when the tick attaches, and so we don't want to agitate the tick in any way that is going to make it salivate more and thereby be more likely to transmit anything."

                                 CDC image

Remove ticks by grasping them as close to the skin as possible with tweezers and pulling straight out with gentle, even pressure. Multiple sources say to not use petroleum jelly, gasoline, hot matches or other "folk remedies" to remove ticks. Dispose of the tick by submersing it in alcohol, placing it in a sealed container or bag or flushing it down the toilet. Once removed, wash the bite area, apply antiseptic and cover with a Band-Aid.

"Never crush a tick with your fingers," warns the CDC.

To protect yourself from ticks, here are some tips from experts:

• Keep grass and shrubs trimmed, and clear away overgrown vegetation; 
• Don't walk through uncut fields, brush and overgrown areas; 
• Walk in the center of hiking trails; 
• Wear light-colored clothing, which makes it easier to spot ticks; 
• Wear long pants tucked into boots or socks and tuck your shirt into your pants; 
• Place a band of duct tape, sticky side out, around your lower legs to trap ticks; 
• Use tick repellent that has DEET or picaridin, or use permethrin-based clothing sprays; 
• Check your body and clothing at the end of each day; 
• Take a warm soapy shower after potential exposure; 
• Check your outdoor gear and pets;
• To kill ticks on clothing, tumble dry for 10 minutes; wash dirty clothes in hot water. If clothes can't be washed in hot water, tumble dry for 90 minutes on regular heat or 60 minutes on high.

Organized sports provide about 20 minutes of real exercise per hour of activity; CDC says children should exercise an hour a day

Wikipedia

By Melissa Patrick

Kentucky Health News

We live in a world where children are more likely to participate in organized sports and activities than to spend time running and playing outside. Most parents seem to think this is a pretty good substitute for exercise, but a new study says otherwise.

The study, published in the Journal of Sports Sciences and Medicine and Science in Sports and Exercise, found that "between sitting while listening to instructions, standing in line while waiting their turn and other parts of practices, only about 30 percent of practice time is actually spent in moderate to vigorous exercise," says the Kansas State University news release.

"In an hour-long practice, the children are still getting about a third of the physical activity they need for the day, but it's still a little bit less activity than people would expect," said Katie Heinrich, director of the KSU kinesiology department's Functional Intensity Training Lab,

The Centers for Disease Control and Prevention says children and teens should have an hour or more of moderate to vigorous physical activity each day, including bone and muscle strengthening activities at least three days a week.

Most of Kentucky's middle school and high school children don't get the recommended amount of physical activity.

According to the 2015 Kentucky Youth Risk Behavior Survey, 63 percent of Kentucky's high-school students said they had not been physically active for at least an hour a day in five or more of the seven days prior to the survey, and 80 percent of them reported they hadn't had an hour of physical activity per day on all seven days.

The results were only a little better for middle-school students, with 52 percent saying they had not been active in five of the seven days prior to the study and 71 percent not active in all seven days.

Heinrich added that the findings of this study doesn't mean organized activities aren't important, noting that in addition to providing some exercise, they also provide "structure, companionship and character-building opportunities." But in addition to this, she said parents need to make sure children have at least 40 minutes a day of active unstructured playtime.

"Organized sports are valuable, but free play activities are needed as well," Heinrich said. "It's important to provide children with opportunities for both."

Nurse practitioners want to change law that requires them to make deals with physicians to prescribe strong painkillers

Nurse practitioners Julie Gaskins, left, and Beth Partin own
Family First Health in Columbia. (Photo by Melissa Patrick)

By Melissa Patrick
Kentucky Health News

Since 2006 Kentucky's nurse practitioners have been able to prescribe Schedule 2 drugs, the highest level of legal painkillers, under the supervision of a physician. Now their lobbying group says it's time to let them work without that restriction because it creates a barrier to care that is badly needed.

Nurse practitioners are advanced practice registered nurses with up to seven years of education, including post-graduate training. They may prescribe medications, diagnose conditions, order and interpret tests, and deliver general care.

Once a Kentucky nurse practitioner works under the supervision of a physician of the same specialty for four years, he or she may prescribe drugs on their own for medical conditions such as high blood pressure or diabetes. But to prescribe Schedule 2 drugs such as opioids, they must have an ongoing “collaborative agreement” with a physician to do so, regardless of their experience.

“A collaborative agreement is for prescribing only; there is no oversight written into the contract,” said Jessica Estes, a psychiatric mental health nurse practitioner in Lewisport. “The physician doesn't have to review any of my charts. I don't have to call the physician every time I write one. I only have to have that collaborative in the event I needed to have a conversation with him,” adding that in her 14 years of practice she has only consulted with her collaborator two or three times.

Estes said nurse practitioners are trained to work independently without any supervision over their prescribing. "In fact, I do tele-psychiatry in Minnesota, where I'm completely independent" under that state's law, she said. "Our scope of practice is actually limited by having to have that collaborator in Kentucky to be able to write those prescriptions."

The American Association of Nurse Practitioners says 22 states and the District of Columbia allow nurse practitioners to practice with no restrictions on prescribing; 16, including Kentucky, have reduced prescriptive authority; and 12 are considered restrictive. Kentucky has more than 5,400 nurse practitioners.

Being able to prescribe Schedule 2 drugs is not just about being able to prescribe pain pills, said Elizabeth "Beth" Partin, a 25-year family nurse practitioner.

“It's not always about pain,” Partin said, adding that the lack of a collaborating doctor leaves a nurse practitioner unable to prescribe medications for anxiety, insomnia, shingles, nerve pain, certain cough medicines or attention-deficit hyperactivity disorder – conditions that are often seen in a primary-care office.

Nurse practitioners often struggle to find a physician willing to sign an agreement for non-scheduled drugs, but it's even harder to find one that will sign an agreement for controlled substances, especially since some insurance companies are refusing to pay for a nurse practitioner's services unless their collaborating physician is also a provider for them.

Jessica Estes, psychiatric nurse practitioner in Hancock County,
testified at a 2014 Senate Licensing & Occupations Committee
meeting about a law that allows prescriptive authority for non-
scheduled drugs after four years of supervision.  (photo provided)

Estes said the psychiatric nurse practitioners in her group experienced this with WellCare, a managed-care organization for Medicare and Medicaid plans. She said because her collaborating psychiatrist was a private physician who accepted no insurance, the group had to change collaborators and ended up signing with a family practice physician who sees enough psychiatric patients to meet the requirements -- and was willing to accept WellCare.

“Last year between the four nurse practitioners, we saw about 2,000 visits that were WellCare clients,” Estes said. “If I had not been able to secure that collaborator that also took WellCare, that's 2,000 patient visits that we would not be able to see in 2017. They would have had to find a new provider.”

She owns Estes Behavioral Health, LLC, which serves more than 6,000 patients, an equal mix of adults and children, from 11 counties. She said about 40 percent of their patients are on Medicaid.

In “most of the counties that we serve, there really aren’t any other providers,” Estes said. “We've not run a single ad in the five years we've been open; it's all word of mouth.”

Partin and her daughter, Julie Gaskins, also a nurse practitioner, are co-owners of Family First Healthcare, a rural health clinic in Columbia. Their practice has over 6,000 patient visits a year, with 72 percent of their patients on Medicare or Medicaid.

Traveling from Partin's clinic in Columbia to Estes' behavioral-
health clinic in Lewisport takes a while. (Google map adapted)

Partin said it takes about three to four months for new patients to get an appointment in Estes' practice, about 124 miles from her clinic. Adair and Hancock counties are in two of the 87 Health Provider Shortage Areas in the state.

Psychiatric collaborative agreements are also hard to secure because Kentucky has such a shortage of mental health providers. The Association of American Medical Colleges reports that Kentucky has 362 active psychiatrists, or 1 for every 12,192 Kentuckians, and almost 40 percent of them are 60 or older. Estes said the state has fewer than 150 psychiatric APRNs.

“I just had a conversation this week with one of my former nurse-practitioner students who would like to do some private practice on her own, and she's called seven psychiatrists and they've all turned her down, because they are either employees of large organizations or they want an amount of money that she couldn't afford to pay,” Estes said.

While some collaborating physicians don't charge anything, most charge between $500 and $5,000 a month, or take a percentage of the nurse practitioner's annual earnings, Estes and Partin said.

Estes said psychiatric nurse practitioners in Kentucky who can't find a collaborator either end up working for a large medical group or hospital, or work in tele-psychiatry in states that don't require such an agreement.

Lobbying and legislating

Legislation to remove the collaborator requirement for prescribing Schedule 2 drugs was introduced during the 2017 legislative session as Senate Bill 158, but did not make it out of committee. The Kentucky Coalition of Nurse Practitioners & Nurse Midwives is in the “early stages” of the legislative process for the 2018 session, said Partin, who has held a leadership role in all nurse-practitioner legislation in Kentucky since 1992.

Her adversaries are the Kentucky Academy of Family Physicians and the Kentucky Medical Association, which have said they do not support any change to the law, contending that it would add to the prescription-drug abuse that continues to plague the state.

KAFP President William C. Thornbury said in a statement,”Family physicians believe SB 158 conflicts with our governor's policy to combat opioid abuse.” The KMA said, “With the ongoing issue of prescription drug abuse and the discussions around the country about the issue, we would oppose any changes to the current law.”

Senate President Robert Stivers, R-Manchester, who voted against the 2006 bill that expanded nurse practitioner's Schedule 2 prescription authority, told members of the Senate Judiciary Committee in March that he would be looking into why “half” of the pain pills written in his hometown of 20,000 were written by nurse practitioners -- a town that has 12 pharmacies and around 150 opioids prescribed per person each year.

Nurse practitioners disputed the alleged connection between the prescribing authority of nurse practitioners and the over-prescribing of opioids, citing data from the Kentucky All Schedule Prescription Electronic Reporting system.

“The problem in Kentucky existed prior to our ability to write those controlled substances,” Estes said. “The KASPER data very clearly shows that we are not the providers that are writing the majority of those prescriptions.”

Heather Shlosser, director of the psychiatric-mental health nurse practitioner program at Frontier Nursing University in Hyden, said efforts to decrease the number of opioid prescriptions will depend on making sure providers are trained to prescribe them based on evidence-based guidelines -- and changing the culture of patients so that they understand that a pill is not always the answer, rather than simply limiting the disciplines that can prescribe them.

“Restricting practice is not helping to expand access and it's not helping to educate the NP any further than where you stop them with the restriction,” she said. “All the literature tells us that the outcomes are the same whether the care is provided by the physician or a nurse practitioner.”

Tammy Adamson, a patient of Partin's: "I've never had an experience here as to

where they didn't give me the time that I needed, and explained things to me."

(Photo by Melissa Patrick)

Gaskins said nurse practitioners are trained to take a holistic approach to care that focuses on education and prevention along with the use of appropriate medications.

Kentucky law only allows psychiatric nurse practitioners to write 30-day prescriptions for ADHD medications with no refills, and primary-care nurse practitioners are limited to a 72-hour prescription.

“That's a huge problem, especially in Kentucky,” said Shlosser, who is also a mental health nurse practitioner in New Hampshire. “Kentucky has the highest rate of children being diagnosed with ADHD, according to the Centers for Disease Control [and Prevention].”

The CDC reports that 19 percent of Kentucky children aged 4 to 17 have ever been diagnosed with ADHD, compared to 11 percent of children nationwide.

Shlosser added that likely means “a huge number of children” in Kentucky need care for ADHD, but don't have access to it or have to wait months or drive great distances to get care.

“That is not helping the 10-year-old kid that is struggling,” she said. “We are as providers constantly telling patients, 'Get treatment, get help, you need to get it together,' but where are they supposed to go if there are no providers?”

This article was produced as part of the Health Care Workforce Media Fellowship of the Center for Health, Media & Policy, New York, N.Y. The fellowship is supported by a grant from the Johnson & Johnson Foundation. Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

McConnell says he doesn't know how he will get votes to repeal and replace Obamacare; his Republican colleagues turn gloomy

Mitch McConnell (Reuters photo by Joshua Roberts)

"U.S. Senate Majority Leader Mitch McConnell said on Wednesday he does not yet know how Republicans will amass the votes needed to pass legislation now being crafted to dismantle Obamacare," Reuters reports. "He declined to discuss what provisions he might want to see in the bill or provide a timetable for producing even a draft to show to rank-and-file Republican senators and gauge their support."

McConnell needs 50 votes plus the tie-breaking vote of Vice President Mike Pence, and "I don't know how we get to 50 at the moment," he told the wire service. "But that's the goal. And exactly what the composition of that (bill) is, I'm not going to speculate about because it serves no purpose."

Republicans hold 52 Senate seats, but some moderates are firmly opposed to the proposed American Health Care Act passed by the House, and some conservatives, including Kentucky Sen. Rand Paul, think the bill wouldn't repeal enough of the 2010 Patient Protection and Affordable Care Act. "The Republican leader compared the effort to solving a Rubik's Cube," Reuters reports.

"Republican senators quickly distanced themselves from a House-passed Obamacare repeal-and-replacement bill after a new analysis of the legislation was released on Wednesday," The Hill reports. "The American Health Care Act would result in 23 million more uninsured Americans over a decade, according to the Congressional Budget Office analysis. The CBO also found that in states that would let insurers charge sick people more, some could be priced out of being able to afford insurance."

McConnell said in a Senate floor speech that the CBO score repeats "things we already know, like that fewer people will buy a product they don't want when the government stops forcing them to," but is a step that will allow the Senate to proceed with its own bill. Still, "It makes everything harder," Sen. Dean Heller, R-Nev., told Politico.

"Senators reported that they’ve made little progress on the party’s most intractable problems this week, such as how to scale back Obamacare's Medicaid expansion and overall Medicaid spending," which are highly important to Kentucky, report Politico's Burgess Everett and Jennifer Haberkorn. "Frustrations are rising and confidence is diminishing. . . . A feeling of pessimism is settling over Senate Republicans."

Republican senators reported being surprised by McConnell’s Wednesday statement, Politico reports: "Though aides said McConnell was restating the challenge of passing a bill in a sharply divided conference, senators said they also did not take the calculating majority leader’s words as a vote of confidence."

“He doesn’t do much that’s not purposeful. So is he sending a message here of: ‘Don’t anybody think this is likely to happen?’” an unnamed Republican senator told Politico. “If I had to bet my house, I’d bet we don’t get it done.”

McConnell recently warned senators and leadership staffers deliberating privately on the issue that he would bar staff members from the meetings if leaks from the conversations continued. Budget Committee Chair Mike Enzi of Wyoming, who is starting to draft the bill, told Roll Call that the number of leaks “seems normal,” but added, “If every idea was voiced out there, then there would be opposition to every idea before it gets finalized.”

McConnell originally named 12 Republican senators to work with him on the bill, but after he was criticized for not naming any women to the work group, he said any Republican could take part in the discussions. "Despite that, Republican leadership has faced criticism for the manner in which the legislation is being crafted," Roll Call's Joe Williams and Erin Mershon reported. "Several members say the bill is not expected to go through formal committee process."

Or through any Democratic senators. McConnell told Reuters that said health care and taxes remain the top priorities for Republicans, and "added that he will not reach out to the minority Democrats on either one because differences between the two parties are too stark," Reuters reports. He said, "They're not interested in doing what we're interested in doing."

Not allowing Democrats to help draft the bill "will leave McConnell, a conservative 75-year-old Kentuckian with a reputation as a dealmaker, a narrow path to win passage of these ambitious goals, which are also at the head of Republican President Donald Trump's policy agenda," Reuters notes.

"McConnell also said he has not asked the White House for input as the Senate devises its own health care legislation after the Republican-led House of Representatives passed its version on May 4, but may do so in the future," Reuters reports. "I told the president there would be a point at which we might well want him and the vice president to be helpful," McConnell said, adding that Trump and Pence could help with "whipping" up support for a bill.

They might also be needed to get votes for any compromise bill that emerges from a House-Senate conference committee -- if the Senate passes a bill.

Wrapping up the week, Mary Agnes Carey asked Kaiser Health News colleague Julie Rovner, "Why do you think Mitch McConnell would send such a public signal that he’s having a problem getting to 50 votes?" Rovner replied, "I really don’t know. I thought it was kind of curious. One of the things that it might be is that he wants to, you know, light a fire under his caucus, who are having all this disagreement, saying you know this whole thing could, you know, just dissolve if you don’t actually start coming to the table and compromising. Why else do you think he might do it?"

Carey said, "Well, you talk about how the calendar is working against him if he wants to get to tax reform. We’re at Memorial Day, and typically tax reform takes a lot of work, a heavy lift, maybe he just wants to move onto that. Rovner asked, "So basically abandon the whole health reform idea?" Carey acknowledged, "I mean, it sounds a little nutty. And obviously it’s a campaign promise they’ve all made. But also, as we’ve seen, there are problems in the marketplace. You do see insurers leaving over uncertainty. Perhaps they want to let that play out. I’m not sure."

"Neither am I," Rovner replied. For their conversation, click here.

State health plan provides free or low- cost diabetic meds and supplies; study finds program improves employees' health

Kentucky.gov photo

An analysis of Kentucky's state-employee health insurance plan, which provides free or reduced-cost diabetic medications and supplies, found this service was helping its members better manage their condition and make better health decisions.

“Many times the cost of medical and pharmacy treatment prohibits members from receiving care,"Jenny Goins, commissioner of the Department of Employee Insurance, said in a news release.

The study found that participants in the Diabetes Value Benefit program showed better adherence to their medications and a 3.5 percent decrease in other prescription drug use. Emergency-room visits were down 10.3 percent, doctor-office visits decreased 3.1 percent and hospital admissions dropped 6.5 percent since 2015.

The DVB program allows members with a diabetes diagnosis to receive maintenance prescriptions and supplies, such as diabetic strips, free or at a reduced copay or coinsurance, with no deductible. KEHP also provides coverage for the Diabetes Self-Management Education program and pays 100 percent of the cost of the Diabetes Prevention Program for those with pre-diabetes.

Chris Biddle, a KEHP member who's been diagnosed with diabetes and participates in the DVB program, said, ""My numbers have improved so much that I ceased taking some of my other cardiac medications and my diabetes medications have been cut in half -- a big savings out of my pocket! I'm now going to the doctor about half as much as I did before."

The Kentucky Employees' Health Plan covers more than 260,000 state employees, retirees and others, and spends more than one million dollars in diabetes claims each year, says the release. More than 23,000 KEHP members were diagnosed with diabetes in 2016, down from 25,000 members in 2015, according to the release.

Kentucky ranks 12th in the nation for diabetes. It’s the seventh leading cause of death by disease in the state.

Kentuckians who are not covered by the KEHP can get information about diabetes resources by visiting the Kentucky Diabetes Resources Directory .

Medicaid managed-care firm WellCare funds scholarships to train more doctors, psychiatrists and advanced-practice nurses in E.Ky.

WellCare of Kentucky is providing $180,000 for two new University of Kentucky scholarship programs aimed at increasing the number of primary-care and psychiatric doctors and advanced-practice registered nurses in Eastern Kentucky.

WellCare, a Medicaid managed-care company, made the announcement May 22 at the UK Center for Excellence in Rural Health in Hazard.   

“We know that access to doctors, nurses and other health care providers directly affects health outcomes,” said Bill Jones, president of WellCare of Kentucky. “When health care is in short supply or located far away, people are less likely to get routine screenings, tests and vaccinations. . . .  Anything we can do to encourage more providers to locate in underserved areas will be a direct benefit to the health of our state.”

Dr. Kevin Pearce, the UK College of Medicine associate dean for rural and community health, said the scholarships would go to students interested in caring for medically under-served Kentuckians. “Kentucky has significant physician shortages, especially in our rural communities, and these scholarships will be helpful in mitigating our physician shortages,” he said.

The WellCare Physicians for the Commonwealth program is partnering with the medical school to provide 20 one-year scholarships worth $5,000 to incoming medical students in the UK Rural Physicians Leadership Program, which provides two years of clinical experience with rural, under-served Kentucky populations, according to a UK news release.

These scholarships will support medical students in the program in Morehead or the new Bowling Green campus, scheduled to open in 2018.

For more information or to apply, contact Julie McDaniel at julie.mcdaniel@uky.edu.

WellCare is also partnering with the UK College of Nursing to provide $80,000 for 10 scholarships for students in its Doctorate in Nursing Practice program who plan on practicing in primary medicine or behavioral health in rural Kentucky.

Interested students should contact Dr. Sheila Melander at sheila.melander@uky.edu.

Ky. is a national leader in hepatitis C, but many counties at risk shun syringe exchanges that could prevent disease outbreaks

"Growing intravenous drug use by people sharing syringes to inject heroin and other substances" has helped make Kentucky a national hotbed for cases of hepatitis C, "which ultimately could mean a staggering cost to taxpayers to treat people with the disease," Bill Estep reports for the Lexington Herald-Leader.

"Giving addicts clean needles can help stem the spread of the disease, but many Kentucky counties considered at greatest risk for an outbreak have not approved such programs," Estep notes. His story has a map of syringe exchanges and the Kentucky counties that the federal Centers for Disease Control and Prevention considers most at risk for an outbreak of HIV or hepatitis C due to IV drug use. Of the 220 counties identified, Kentucky has 54, almost half its total number of counties.

Lexington Herald-Leader map

"The programs have only been legal in Kentucky since 2015, when the legislature authorized them in the face of mounting IV drug use," Estep notes. Now there are 33, nine of which are not in operation yet. They are run by local health departments with approval of the county fiscal court and the city where the exchange is located.

"Despite the documented problems, more than 30 of the counties the CDC identified as being at high risk for a disease outbreak have not set up needle-exchange programs," Estep reports. "Some local officials said they’ve faced concerns from residents of their culturally and politically conservative counties that giving needles to drug users condones or perpetuates drug abuse."

Russell County Judge-Executive Gary Robertson "said he had much the same reaction when the idea first came up but changed his mind after learning more," Estep writes. "Drug addicts will find needles and use drugs with or without a local needle-exchange program, but the program can help reduce the spread of expensive diseases, Robertson said."

Studies show that people who use exchanges are much more likely to get drug treatment, Estep notes. "Other studies have shown that exchange programs don’t encourage people to start taking drugs or increase how often users inject drugs; that they don’t increase crime; and that they help reduce the problem of drug users disposing of dirty needles improperly."

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

The CDC said recently "that in 2015, Kentucky was among seven states where the incidence of new hepatitis C cases was more than twice the national rate," Estep reports. "Kentucky, West Virginia and Massachusetts had the highest rates, the May 12 report said. The problem has been building for years, according to the 2017 update to the Kentucky Department for Public Health’s state health assessment. The update, released in March, said Kentucky had the highest rate of new hepatitis C infections in the nation from 2008 through 2015, the last year with available data." Kentucky also has the second highest rate of babies born to mothers with the disease, trailing only West Virginia.

Those mothers need to be identified and treated before delivery, said Dr. Ardis Hoven, an infectious disease specialist with the state health department.“We have an epidemic, and we need to continue to deal with it,” she told Estep.

Treating hepatitis C is expensive, Estep notes: "In the last full fiscal year, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries, or $83,735 apiece, according to the Cabinet for Health and Family Services."

This week, Sen. Mitch McConnell can start making decisions about what Senate Republicans will put in their health bill

U.S. Sen. Mitch McConnell's role in the national health debate "will come into sharp relief this week," Burgess Everett and Jennifer Haberkorn report for Politico. "He will decide the contents of the Senate’s plan, most likely behind closed doors. And he is on the hook for getting something through a sharply divided Senate Republican Conference in the midst of an increasingly imperiled presidency."

The first shoe will drop Wednesday, when the Congressional Budget Office delivers "a highly anticipated report on the House health-care bill that is expected to show it would cause huge coverage losses," Politico notes. "That will provide a new round of ammunition to Obamacare supporters, even as it allows the Senate to truly start writing its own plan."

McConnell, who as majority leader named a 13-member working group to come up with the outlines of a bill, has been meeting with senators "without making substantive progress, according to attendees," Politico reports. "In the coming days, McConnell will have to move to break the impasse."

Sens. Lamar Alexander and Mitch McConnell (Getty Images)

The Kentuckian has given no clue to what he might do in concert with Sens. Lamar Alexander of Tennessee, Orrin Hatch of Utah and Mike Enzi of Wyoming, chairs of the key committees that will handle the bill publicly once it is drafted privately.

“Mitch right now is listening very carefully. He’s being very careful not to weigh in, thinking that this needs to come from the membership,” an unnamed GOP senator told Politico. “He’s not trying to force a particular point of view.”

"Only the faintest outline of a plan is taking shape," Politico reports. "Senators are working to make the House bill's tax credits more generous and to find a way to wind down Obamacare’s Medicaid expansion more slowly," instead of 2020. "The Senate is expected to repeal many Obamacare regulations but not go as far as the House did in rolling back protections for people with preexisting conditions." The House bill would give the states power to do that.

"The idea, according to several lawmakers, is that if the relatively ideologically diverse working group can agree to get behind a bill, that would get the GOP close to 50 votes," the point at which Vice President Mike Pence would break the tie in favor of Republicans. But it would be up to McConnell to get to 50, and that will be difficult.

“It’s pretty easy to put together 46 or 47,” said Sen. Roy Blunt (R-Mo.). “It’s getting to 50 that’s a challenge.” One obstacle may be Kentucky's other senator, Rand Paul, who is out of the Senate mainstream, saying the House bill didn't go far enough.

Senate Majority Whip John Cornyn of Texas said there will be a vote on the bill by late July, before the August recess, but "Some doubt that aggressive timeline," Politico reports. "Some Republican senators were privately hoping it would never reach this point. They would have preferred that the House bill fail, to spare them having to take up a measure they believe would cause too many people to lose insurance and do too little to lower premiums."

Kentucky's only Democratic member of Congress, Rep. John Yarmuth of Louisville, said recently that McConnell would not allow a health bill to come to a vote in the Senate, for fear of political repercussions in the 2018 elections. But Politico reports, "McConnell wants to have a vote on an Obamacare repeal bill, whether it passes or not, so the Senate can move on to tax reform and spending bills."

It would be unusual to bring a bill to a floor vote without a guarantee of passage, but that seems possible in this case. “We’re on a track to write a bill and vote on it,” Alexander told Politico; whether it will be successful, “I can’t say.”

Trump budget will include big cuts to Medicaid, maybe work rules

The detailed budget that the Trump administration will release Tuesday will contain big cuts to Medicaid, reflecting the approach of the health bill that House Republicans sent to the Senate this month, The Washington Post reports.

"Trump’s decision to include the Medicaid cuts is significant because it shows he is rejecting calls from a number of Senate Republicans not to reverse the expansion of Medicaid that President Barack Obama achieved as part of the [Patient Protection and] Affordable Care Act," Damian Paietta writes for the Post. "The House has voted to cut the Medicaid funding, but Senate Republicans have signaled they are likely to start from scratch."

"Trump offered a streamlined version of the budget plan in March, but it dealt only with the 30 percent of government spending that is appropriated each year," Paietta notes. "Tuesday’s budget will be more significant, because it will seek changes to entitlements — programs that are essentially on auto­pilot and don’t need annual authorization from Congress. The people describing the proposals spoke on the condition of anonymity because the budget had not been released publicly and the White House is closely guarding details."

The budget plan "also will call for giving states more flexibility to impose work requirements for people in different kinds of anti-poverty programs," Paietta reports. The story does not mention work requirements for Medicaid, but the opportunity for states to set such rules would not be a surprise, since it is in the House bill, and the proposed Medicaid plan for Kentucky includes them and was drafted by Seema Verna, the director of the Centers for Medicare and Medicaid Services.

National committee studying health impacts of surface coal mining in Central Appalachia to have first meeting in region Tuesday

A national committee studying the health impacts of surface coal mining in Central Appalachia will have its first public meeting in the region Tuesday, May 23 at Chief Logan State Park near Logan, W.Va.

The committee of the National Academies of Sciences, Engineering, and Medicine had a meeting in Washington on March 7, and has another one scheduled there for July 11. The site of a fourth meeting, set for Aug. 21, has not been announced. The study focuses on  West Virginia, Kentucky, Virginia and Tennessee.

At Tuesday's meeting, representatives from West Virginia Bureau for Public Health, the West Virginia Department of Environmental Protection, the West Virginia Coal Association and several environmental groups will participate in panel discussions form 12:45 to 3:45 p.m. From 6:30 to 9 p.m., a town hall meeting will allow community members will have an opportunity to address the committee. For a detailed agenda, click here.

The study is funded by a $1 million grant from the federal Office of Surface Mining Reclamation and Enforcement. It is examining research, primarily done by Indiana University's Michael Hendryx when he was at West Virginia University. Another study, by the National Institute of Environmental Health Sciences, is in process.

Paul tells doctors and officials at Ashland hospital, a beneficiary of Medicaid expansion, that the country can't afford to keep it

Sen. Rand Paul at the hospital. (Daily Independent photo by Rachel Adkins)

The nation can't afford to continue the expansion of Medicaid, U.S. Sen. Rand Paul told doctors and officials Friday in Ashland at King's Daughters Hospital, which has benefited greatly from the expansion.

"We don't have any money; we have a printing press," said Paul, a Bowling Green eye surgeon. "And we borrow $500 billion a year. And there is the question: Could we ultimately destroy the country with that much debt? I call it the big-hearted, small-brain syndrome, which is very, very prevalent in Washington. They are sympathetic, they want to help people. We all do. But the thing is, if you destroy the country helping people, would you be better off or worse off?"

Before the Patient Protection and Affordable Care Act, Medicaid paid for "about 17 percent of patients in the King's Daughters Health System," Adam Beam reports for The Associated Press. Now that the law has added 470,000 Kentuckians to the rolls, "Medicaid pays for 23 percent of patients at the hospital system on the Kentucky-Ohio border."

The health bill sent to the Senate by the House would end the Medicaid expansion after 2020. Not having the expansion "would be the difference between staying open and not staying open," Chief Medical Officer Richard Ford told Beam.

King's Daughters' share of uninsured patients fell to 2 percent from 11 percent after Medicaid was expanded in 2014. "But despite the hospital's dependence on Medicaid, the amount of money the hospital made from each of those newly insured patients fell, too," Beam reports. "Ford says the system struggles to make a profit."

"It was more of a redistribution from one patient to the next more than it was helping us with covering our own expenses," Ford told him.

"Paul's solution to fix all of this is to make the health care system more market-based," Beam reports. "He wants to make it legal for people who don't get health insurance from their employer to join together with others in nationwide "health associations" to increase their bargaining power. Imagine, he said, if the National Rifle Association's more than 5 million members were able to join forces and negotiate with health insurance companies as a group instead of individually."

Garfield Grandison, a gastroenterologist, told Paul that he and other senators should consider more factors than cost. "Grandison and a local social worker said they’re concerned patients suffering from mental health and substance abuse problems could be hurt by the ACA replacement," because those would no longer have to be covered by health insurance, Andrew Adkins reports for the Ashland Daily Independent.

Paul said that would make premiums go down, and "said the fundamental question is based, for instance, on if a 72-year-old should be forced to pay for special procedures for others, such as pregnancy, in a free society," Adkins reports.

Grandison replied, "Should I be forced to drive on every single road my taxes pay for, or use every park my taxes help pay for? I understand from the standpoint of cost, where you’re going. You’ve made a good argument on cost, but there are other aspects that should be considered and part of the debate."

Study of Ind. Medicaid, proposed model for Ky., finds more than half of enrollees missed paying a premium and thus lost coverage

By Melissa Patrick
Kentucky Health News

Kentucky's plan to change Medicaid would require poor people to pay small, income-based premiums for coverage. That creates a barrier to health care, says a study of Indiana's similar plan allowed by a federal waiver.

“During the first 21 months of the waiver program, 324,840 (55 percent) of the 590,315 people eligible to pay didn’t make a required payment at some point. All of them were then kicked off of Medicaid or were left with inferior coverage," the liberal-leaning Kentucky Center for Economic Policy said on its policy blog.

Indiana's program requires enrollees to pay between $1 and $100 a month, depending on income, to participate in the plan with the most benefits, including dental and vision. This is the only plan available to Hoosiers above the federal poverty line.

If the enrollees fail to make a payment, those above the poverty line are disenrolled and locked out of the program for six months, while those in poverty are moved to a more limited plan that requires co-payments for all services, has lower service limits and limited drug benefits, and does not include dental and vision benefits.

Under Kentucky's proposed waiver, those who fail to pay would face a six-month lockout unless they pay back three months' worth of premiums and take a financial or health literacy class. Kentucky's plan does not include dental or vision benefits, though these benefits can be earned through a rewards program. This plan is expected to be approved in June, and to go into effect Jan. 1.

Kentucky's plan is modeled after Indiana's. Both were designed by Seema Verma, the new administrator for the Centers for Medicare and Medicaid Services. She has recused herself from the decision on Kentucky's plan, but it's expected that under her leadership other states will be allowed to impose similar monthly fees.

The proposed premium requirements in Kentucky's waiver plan, called Kentucky HEALTH, are based on income and the length of time a person is enrolled, if above the poverty line.

Premiums would be $1 to $15 per month, based on income, and would rise in incremental limits for those above the poverty line after the second year to a limit of $37.50. The federal poverty line for an individual is annual income of $12,060.

The Indiana plan, which took effect in 2015, was evaluated by the Lewin Group, a health-care consulting firm, using almost two years of data.

Among the 55 percent who had missed a premium payment, most (57 percent) were at or below the poverty level, which allowed them to drop to the lower-tier plan instead of being locked out.

"We can expect large numbers of Kentuckians to be left without coverage if the waiver is approved by the federal Department of Health and Human Services," KCEP said. "The assessment of the Indiana waiver confirms that both the cost and process of paying premiums is a barrier to coverage for low-income people."

The report, which was limited to Indiana, and the KCEP did not estimate how many Kentuckians might regain coverage by getting premiums up to date and taking a health or financial literacy course.

The report found that almost half of those who were kicked off the Indiana program or never made an initial payment did have insurance, mostly through an employer, "but that means that 53 to 59 percent were without health-care coverage of any kind," said KCEP.

The most common reasons enrollees gave for not paying premiums were that couldn't afford it, they were confused about the payment process, or didn't know they were required to make a payment.

The report also looked at access to care and found that people who were kicked off coverage or never enrolled were less likely to make appointments for care or fill a prescription in the previous six months.

Kentucky's plan is expected to save $2.2 billion over the next five years, of which the state's portion would be $331 million, according to the state's waiver request. It estimates that after five years, the state's Medicaid rolls would have 86,000 fewer people than an unchanged program would have. About 30,000 people a month go on and off Medicaid in Kentucky as their circumstances and incomes change.

Beshear joins lawsuit to defend Obamacare cost-sharing subsidies; D.C. appeals court to consider request Monday

By Melissa Patrick
Kentucky Health News

Kentucky Attorney General Andy Beshear and 15 of his counterparts have filed a motion aimed at maintaining cost-sharing subsidies for health insurance for low-income people under the Patient Protection and Affordable Care Act. The attorneys general want a federal court to let them directly defend the subsidies, about which the Trump administration has been ambivalent.

In 2014, House Republicans sued the Obama administration over the legality of these cost-sharing subsidies being paid to insurance companies because Congress never appropriated the funding for them. A district court ruled in favor of the House, but the Obama administration appealed the ruling. The subsidies were allowed to continue pending the appeal.

When Obama left office, the Trump administration became the defendant in the lawsuit. The administration is scheduled to inform the U.S. Court of Appeals for the District of Columbia Circuit on Monday, May 22, how it wants to proceed with the appeal.

Harris Meyer of Modern Healthcare reports, "The state attorneys general claim their states' interests would be gravely harmed if the payments stop because many insurers would exit the individual insurance market, premiums would spike, many of their residents would be left uninsured, and state and local governments would face heavy costs in paying for medical care for the newly uninsured people."

Beshear said in a news release, “Thousands of Kentuckians who purchase health insurance from the federal exchange are at risk of losing access to affordable health care coverage. The loss of federal funds and the financial uncertainty threatened by the case would lead to higher health insurance costs for Kentuckians and to insurers abandoning the individual health insurance market.”

The Kaiser Family Foundation projects that without the cost-sharing subsidies, premiums would increase by an average of 19 percent on ACA "silver" plans, the most popular, and higher in states that have not expanded Medicaid. The subsidies are available to people with incomes between 100 and 250 percent of the federal poverty level -- between $24,300 and $60,750 for a family of four.

Kentucky has extended its deadline for filing 2018 Obamacare plans to June 7, from the original May 17, "to allow insurers more time to obtain relevant data, including enrollment and claims data for the beginning of 2017, for use in developing assumptions utilized by actuaries to determine necessary plan pricing," Ronda Sloan, spokeswoman for the state Department of Insurance, told Kentucky Health News in April.

During the 2017 open enrollment period, 81,155 Kentuckians enrolled for coverage through the exchange and four out of five of them received a subsidy to help pay for their premiums, according to the Kentucky Center for Economic Policy. 

Both the ACA and the House-passed health bill, called the American Health Care Act, include subsidies, but use different formulas. The ACA takes family income, local cost of insurance and age into account, while the AHCA bases its tax credit only on age, with a phase-out for individuals with incomes above $75,000. It would continue the cost-sharing subsidies until 2020, "but would not appropriate those funds, leaving insurers uncertain whether they would receive the payments," Modern Healthcare reports.

Subsidies to low-income consumers who sign up for insurance on the exchange are estimated at $7 billion this year, according to the Congressional Budget Office.

Politico reports that Trump has told his advisers that he wants to end the Obamacare subsidies to force Democrats to the table to negotiate an Obamacare replacement.

The states seeking to intervene in the case are California, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, New York, Pennsylvania, Vermont and Washington, as well as the District of Columbia.

Second town in tobacco-loving Grayson County goes smoke-free; local Population Health Committee's efforts helped

Clarkson, in Grayson County (Wikipedia map)

By Melissa Patrick
Kentucky Health News

Two of the three towns in Grayson County now have smoke-free ordinances, partly as a result of a campaign led by the CEO of the local hospital.

Clarkson, with an estimated population of 900, became the second city in the county of 26,000 to enact a city-wide smoking ban. Leitchfield, the county seat, population 6,900, became smoke-free Jan. 1.

The Clarkson City Commission approved the ordinance by a 3-2 vote at a special called meeting May 1, Theresa Armstrong reports for the Grayson County News-Gazette.

Twin Lakes Regional Medical Center CEO Wayne Meriwether, a smoke-free advocate who leads a local Population Health Committee, said in a telephone interview that Clarkson's ordinance will take effect immediately and is stronger than Leitchfield's ordinance because it not only includes all public places, as Leitchfield's does, but also workplaces.

“Those commissioners that were in favor of it . . . wanted to send a message that their community was progressive and that they wanted to do what was in the best health interest of their community. So they took a strong stance on it,” Meriwether said.

Clarkson Commissioner Ed Schott voiced concern at the meeting about the distance smokers must stand from an establishment's door under the ordinance, Armstrong reports. “The front porch of the funeral home is not 15 feet from the door in any direction, and, at the ball field, the concession stand is not 15 feet away,” Schott said. “I would like us to remove this restriction from the ordinance.”

Schott and Mayor Bonnie Henderson, at the March 13 meeting, told the commissioners that the general consensus of the city's local businesses was that most of them were already smoke-free, but didn't want a law telling them how to run their businesses, Armstrong reported in March.

Despite these concerns, the ordinance passed. Schott, who originally supported the ordinance, and Henderson, who had always opposed it, voted against it; Commissioners Bob Vincent, Joyce Bell and Kay Gibson voted in favor of it.

The Population Health Committee, which is made up of representatives from the hospital, local schools, the health department, city government, local industries and other interested citizens, has led smoke-free efforts in Grayson County, where tobacco was once the main cash crop and its heritage remains strong. The county's estimated smoking rate is 34 percent; the state rate is 27 percent.

Initially the committee worked to pass a countywide ban, but that effort died last year for lack of a second reading in the Grayson County Fiscal Court, despite strong local support and a survey that found 82 percent of the people in the county wanted it.

Meriwether said the committee decided to advocate for smoke-free laws "community by community" after the county-ban failed. Caneyville, estimated population 620, is the only incorporated community left in Grayson that hasn't passed a ban.

“That's been the goal all along: Leitchfield, Clarkson and then Caneyville,” Meriwether said. “That would be the biggest part of our county, if we can get all three communities to have ordinances.”

He added, “We have their packets all ready!” The committee has prepared information packets that include facts about the dangers of second-hand-smoke and the results from the countywide survey.

Hospital CEO Wayne Meriwether and Ellen Hahn, director
of the Kentucky Center for Smoke-Free Policy (UKNow photo)

Leitchfield and Meriwether were recently honored at the Kentucky Center for Smoke-Free Policy's annual conference for their efforts in promoting smoke-free workplaces.

Leitchfield city leaders were presented with the "Smoke-Free Indoor Air Endeavor" award and Meriwether was honored with the "2017 Lee T. Todd, Jr. Smoke-free Hero" award for his advocacy of smoke-free ordinances and getting rural hospitals to push for them, reports the News-Gazette.

“I was really happy to see Leitchfield was recognized," he said. "It took a lot of courage for them to be the first one and their city council took some heat, but they did the right thing and they listened to their constituents that wanted it, which was the majority of them.

“And I appreciated getting an award, but that really should go to all of our Population Health Committee members and others that advocated for the ordinance -- a lot of people did.” he said.

Meriwether said his interest in the subject was spurred by concern for children. “We moved from Leitchfield from Henderson, Kentucky, about five years ago. . . . Henderson went smoke-free about 10 to 12 years ago and my children had, didn't remember any place where people smoke. The first restaurant we went to when we moved to Leitchfield, we walked in, and my daughter said, 'What's that smell?' And I said, well, they allow smoking in here. And she said, 'I didn't think anyplace allowed smoking.'

“The point is, in just a few years you can make such a difference and change so many lives. So my kids were never exposed to cigarettes, they weren't allowed anyplace, and so they both grew up as nonsmokers. And that is the kind of effect an ordinance can have.”

The Population Health Committee came out of the hospital's Community Health Needs Assessment, which is required every three years under the Patient Protection and Affordable Care Act.

In addition to its smoke-free advocacy work, the committee actively works on initiatives around nutrition and obesity, increasing opportunities for physical activity and improving community awareness about health and wellness.

"We felt like it was a responsibility for us to try to make a difference," Meriwether said of the committee. "I think it is a real model for hospitals to follow to try to make a difference in the communities that they serve."

He stressed the importance of community partnerships to improve the health of its citizens.

"We may have initiated the committee," he said. "but it takes a lot of people to make a difference."