Stop looking at the wrong end of the elephant: The cost of health care is the real problem that needs solving, writer says

By John Winn Miller
Republished from the Lexington Herald-Leader

   Americans will always be at loggerheads about health-care reform until we stop acting like the blind men trying to describe an elephant by touching only one part of the animal.
   Look at the whole elephant and you’ll see the cost of health insurance is the tail end of a much bigger problem.
   Republicans promised to cut premiums for many by reducing the number insured and what has to be covered, which doesn’t address the real problem: the cancerous growth in health-care costs.
   That’s because insurance premiums are largely driven by three factors: the number and health of people covered, what’s covered and, most important by far, the cost of delivering health care.
   Do the math.

   The United States spent $3.2 trillion on health care — 17.8 percent of gross domestic product — in 2015, according to the Centers on Medicare and Medicaid Services. That’s more than any other nation, according to The World Bank, for worse outcomes on life expectancy, infant mortality and other measures, a 2014 Commonwealth Fund study found.
   Our annual cost is projected to grow 5.8 percent a year, or 1.2 percent faster than GDP growth through 2025, according to the CMMS.

John Winn Miller

   Say what you will about the 2010 Affordable Care Act (or Obamacare), the CMSS statistics show the growth in health-care spending as a percent of GDP slowed dramatically since it was passed. (How much the ACA deserves credit is debatable, but it helped.)
   Reducing the number of people covered, or the quality of their insurance, doesn’t slow that growth. It merely shifts the burden.
   Blame President Ronald Reagan. In 1986 he signed the Emergency Medical Treatment & Labor Act ensuring access to emergency services regardless of ability to pay.

   The federal government reimburses hospitals for some charity care costs. But they either absorb much of it or pass it on via higher charges to patients and insurance companies, which means higher premiums.
   In Kentucky alone, the Affordable Care Act cut uncompensated care between 2012 and 2015 by 76.9 percent, from nearly $2.4 billion to $552 million, according to a 2016 report by the Foundation for a Healthy Kentucky.
   So while the growth in some people’s premiums may slow down at first under Republican plans, millions who lose insurance and Medicaid coverage (voluntarily or not) will flood emergency rooms.    Typically, they are sicker and more expensive to treat because they’ve had no preventative care. It’s like trying to save money by not replacing the oil and spark plugs in your car — sooner or later you’re going to pay a ruinous bill.
   Many Republicans argue the marketplace, freed from government interference, will drive down costs. That didn’t work before Obamacare and it won’t work now because there’s no transparency in medical costs, no market constraints on drug prices and rarely time for a consumer to research prices.
   So, we need to stop looking at the wrong end of the elephant. Otherwise, the pachyderm will morph into a lion that will maul one-sixth of our economy.

John Winn Miller is a former journalist who now produces independent movies.

Read more here: http://www.kentucky.com/opinion/op-ed/article163324908.html#storylink=cpy

Read more here: http://www.kentucky.com/opinion/op-ed/article163324908.html#storylink=cpy

Syringe exchanges and drug therapy can quash 3/4 of hepatitis C cases; experts want treatment barriers cut, but that'll cost money

By Melissa Patrick
Kentucky Health News

Kentucky leads the nation in new infections of hepatitis C, a liver disease now driven mainly by intravenous drug use. It could be virtually eliminated, but that would require a committed strategy to increase syringe exchanges, medication-assisted therapies, and cutting treatment restrictions such as a ban on treating active intravenous drug users.

That was the overarching message to almost 300 people who attended the fourth annual Viral Hepatitis Conference in Lexington July 27. They also heard that Kentucky is working on all three fronts, but not going as far as some experts want when it comes to treating drug users.

"Hepatitis can be eliminated," Homie Razavi, director of the Center for Disease Analysis, an independent research group based in Lafayette, Colo. "The key is to increase harm-reduction programs and basically remove all restrictions, and the final catch is we have to expand it to treat everyone, whether they are 15 or 74."

Razavi said studies show if you only have a syringe-exchange program, it reduces new hepatitis C infections by 15 percent; if you only offer medication-assisted therapies, they reduce the rate by 50 percent; but if you have both, that cuts it 75 percent.

"These programs are very, very effective. They are very cost-effective," Razavi said. But he added, "At the end of the day harm-reduction programs can only go so far.”

More than 38,000 Kentuckians are estimated to be chronically infected with the disease, and many don't know they are, because it can take decades for symptoms to appear. If left untreated, hepatitis C can cause liver damage from cirrhosis or fibrosis, liver cancer, and even death.

Kentucky has the potential to get a lot more hep-C cases, quickly. The federal Centers for Disease Control and Prevention has identified 54 Kentucky counties among the 220 most vulnerable in the nation to a rapid spread of HIV and hepatitis C infection among persons who inject drugs. Sixteen of the state's counties ranked in the nation's top 25.

In 2015, the Kentucky legislature authorized syringe-exchange programs that let drug users swap dirty needles for clean ones to thwart the spread of HIV and hepatitis. But if they want special state funding, the administration of Gov. Matt Bevin requires them to have a one-for-one exchange policy, which experts discourage.

"I cannot underscore enough, one-for-one exchange is not an effective public health intervention," Wayne Crabtree, who oversees the syringe exchange in Louisville, told the group.

"Exchange is not about syringes, it's about the relationship"

As of July 25, Kentucky had 26 operating syringe exchanges and eight that have been approved but not operational, according to the state Cabinet for Health and Family Services.

Crabtree called the Louisville program a "sad success," since it has had more than 11,000 participants since it opened in 2015, with 4,790 returning. He said that in addition to reducing infection rates and offering other important harm reduction services, syringe exchanges can lead people who inject drugs to testing, counseling and treatment.

“Studies show that program participants were five times more likely to enter drug treatment than IV drug users who did not participate in syringe exchange programs. That's amazing!” he said. “Syringe exchange is not about syringes, it's about the relationship. And if you are in relationship with someone and they know you care, you have the makings of change."

State infectious-disease specialist Dr. Ardis Hoven, one of the moderators, said she appreciated Wayne's efforts as "we continue to push and pull and shove and make our voices heard in public health around this very, very important issue."

Eliminating barriers to treatment has its own barriers

Razavi said a successful strategy to eliminate hepatitis C must also allow IV drug users and people who are in the early stages of the disease to be treated. Those restrictions have been reduced in some commercial and veterans' insurance policies, but remain in Kentucky's Medicaid program – which provides care to about one-third of the state's people, generally those with incomes up to 138 percent of the federal poverty line.

Dr. Gil Liu, the state medical director for Medicaid, said 10,500 Kentuckians on the program had been diagnosed with hepatitis C, costing the federal and state governments an average of $83,735 for each case. "In the last full fiscal year, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries," according the cabinet, the Lexington Herald-Leader reported in May.

State Medicaid rules allow hepatitis C treatment only during advanced stages of the disease, which Liu called "very restricted." He said, "We want everybody to have access. We are moving toward relaxing those requirements."

But one restriction, which requires a person being treated to not inject an illicit drug for six months prior to treatment, doesn't seem as likely to be relaxed. Liu said the rule was "under discussion" but there is concern that if it is relaxed, people who use IV drugs won't seek "the full continuum of care" needed to overcome their addictions.

However, Jon Zibbell, senior public-health analyst for the Behavioral and Urban Health Program at RTI International, an independent nonprofit research institute, said that if active injectors can be treated, fewer people would be infected, and therefore fewer to transmit the disease.

“Let me make it clear, we will never control the epidemic unless we treat people who are actively using,” Zibbell said. “Scientific fact.”

Liu eventually got to the crux of the matter: money.

He said it will soon be "financially unsustainable" to support the state's "heroic expansion of eligibility of Medicaid," and he wasn't sure how the state would or could pay to treat everyone for hepatitis C if all restrictions on treatment were removed.

"It very quickly becomes a question of what are you going to ration; that is a zero-sum-game at some point in time," Liu said.

Razavi said research has proven that "the cost of inaction is actually more costly than elimination" of hepatitis C. He said the cost of new, life-saving pills that have a 100 percent cure rate have dropped from $80,000 to $35,000 and lower.

"From a health-care perspective, the state of Kentucky is going to pay for these people. So whether you treat them or don't treat them, they are going to cost you – in fact more if you don't treat them."

The World Health Organization defines the elimination of hepatitis C as reducing the number of new infections by 90 percent and reducing the number of liver-related deaths associated with it by 65 percent before 2030.

Thwarted again, Republicans in Washington are divided about whether to keep trying to pass a health-insurance bill

Pence, McConnell and Trump in happier days (Getty Images)

By Al Cross
Kentucky Health News

After his last-ditch attempt to pass a health-insurance bill failed early Friday morning, Senate Majority Leader Mitch McConnell said, "It's time to move on," and scheduled other business.

President Donald Trump, hungry for a legislative victory, did not agree.

"Unless the Republican Senators are total quitters, Repeal & Replace is not dead! Demand another vote before voting on any other bill!" Trump said Saturday on Twitter.

Trump aides confirmed Sunday that the tweets are presidential policy. "The president will not accept those who say, quote, 'It's time to move on'," Trump adviser Kellyanne Conway said on "Fox News Sunday."

Some House Republicans also said work on health insurance should continue, but they are scheduled to recess at week's end. "The Senate is scheduled to work another two weeks," The Associated Press notes. "McConnell has said the unfinished business includes addressing a backlog of executive and judicial nominations, ahead of a busy agenda in September that involves passing a defense spending bill and raising the debt limit."

In several tweets, Trump called on McConnell and other Republican senators to eliminate the filibuster, which effectively requires 60 votes to pass significant legislation.

“The very outdated filibuster rule must go. Budget reconciliation is killing R's in Senate. Mitch M, go to 51 Votes NOW and WIN. IT'S TIME!” Trump wrote. “Republicans in the Senate will NEVER win if they don't go to a 51 vote majority NOW. They look like fools and are just wasting time.”

McConnell has repeatedly said that he will not support eliminating the filibuster, and "a McConnell aide said it's not going to happen," reports John Bennett of CQ-Roll Call.

In another tweet, Trump threatened to cut off subsidies of insurance for people whose incomes are less than 250 percent of the federal poverty level, or a family of four with annual income of about $85,000: "If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!" he wrote Saturday.

After seven years of "talking" Repeal & Replace, the people of our great country are still being forced to live with imploding ObamaCare!

— Donald J. Trump (@realDonaldTrump) July 29, 2017

In an aside during a speech Friday, Trump repeated his threat to "let Obamacare implode." Insurance companies say ending the subsidies would further destabilize Obamacare's individual insurance market. The Kaiser Family Foundation has estimated that it would raise the cost of a typical plan by 15 percent in states that expanded Medicaid (including Kentucky) and 21 percent in other states.

Sen. Susan Collins of Maine, one of three Republicans to vote against McConnell's bill and a former state insurance commissioner, said Trump's threats have already "contributed to the instability in the insurance market" and "I seriously hope that in the meantime the president doesn't do anything to hasten that collapse." She said the payments are "not an insurance company bailout but help people who are very low income avoid their out-of-pocket costs . . . It would really be detrimental to the most vulnerable citizens if those payments were cut off."

Office of Management and Budget Director Mick Mulvaney told Jake Tapper on CNN's "State of the Union" the president's tweets reflect official policy, and "I think what you see there is simply the president reflecting the mood of the people. . . . You can't promise folks you're going to do something for seven years and then not do it. . . . They need to stay, they need work, and they need to pass something."

Mulvaney said Trump's congressional bailout reference was to an Office of Personnel Management decision two years ago that "allowed a special exemption to the rules on employer contributions to those plans." The rule insulates members and staff from premium increases on the government insurance exchange by allowing them to get employer contributions from the government to pay for plans on the small-business exchange for the District of Columbia.

As Trump called for action, some Republicans in the House and Senate met to discuss how that could be done. Rep. James Comer of Western and Southern Kentucky's 1st District "said he expects the next steps for health-care reform to include bipartisan efforts," Sarah Loesch reports for The Gleaner in Henderson.

McConnell said in late June that if Republicans did not agree "and change the status quo . . . markets will continue to collapse and we’ll have to sit down with Senator [Chuck] Schumer,” of New York, the Democratic leader. “Doing nothing is not an option.” McConnell has not repeated that warning, at least not publicly, and has seemed wary of a bipartisan approach.

McConnell said after his bill died Friday that he wanted to hear ideas from Democrats, but "Bailing out insurance companies without any thought of reform is not something I want to be part of."

Sen. David Perdue (R-Ga.) said that when he heard Schumer say early Friday that Obamacare needs major reforms, he started talking to Democrats about compromises, but other Republicans suggested they would oppose bipartisan talks.

“I don’t think the Democrats have any interest in doing anything productive” on health care, said Sen. Ted Cruz (R-Tex.). “Republican senators are going to go home. They’re going to hear from their constituents, and I don’t expect the response to be muted.”

Collins said "the first bill we should consider" is one to stabilize the insurance market, and called for a bipartisan approach, as did Sen. John McCain of Arizona when he returned from a brain-cancer diagnosis to cast a vote allowing debate on the issue last week. McCain cast the deciding vote against what he called McConnell's "shell bill" that the leader said was designed to take the issue to a House-Senate conference committee. The votes of McCain, Collins and Alaska's Lisa Murkowski made the tally 51-49. "Most people expected a tie," Collins said Sunday.

The cost-sharing subsidies expire Monday, July 31, and other deadlines loom.

"The drawn-out health care debate on Capitol Hill has left lawmakers and administration officials with very little time to reassure jittery insurers that the markets created by the ACA will be stable enough for them to offer plans at a reasonable rates," Ed O'Keefe reports for The Washington Post. "Companies must set their final rates by Aug. 16 and states must submit the rates they’ve approved to federal officials by Sept. 27."

Sens. Lindsey Graham has an alternate plan and met at the White House on Friday with Sens. Bill Cassidy of Louisiana and Dean Heller of Nevada, fellow Republicans. "The bill’s supporters are telling administration officials and congressional aides that the bill will score far better than previous efforts, which CBO analyses project would cause millions more uninsured people and short-term spikes in premiums," report Burgess Everett, Josh Dawsey and Rachel Bade of Politico.

"Several senior Republican Senate aides and allies of GOP leaders cautioned against any feelings of momentum coming from the White House on Saturday," especially after Trump's tweets about the filibuster. "McConnell has resisted such a suggestion publicly and has been pushing back against Trump privately, according to people familiar with their interactions. One person close to McConnell said Trump has asked McConnell personally to change the rules but said no."

The Politico reporters add, "Senate rules don’t appear to be the problem. From the 'skinny repeal' bill to a McConnell designed replacement bill to a so-called “clean” repeal bill, all GOP efforts failed to get 50 votes in the Senate," at which point Vice President Mike Pence could break the tie in Republicans' favor.

The Post's Mike DeBonis and Amber Phillips write that congressional Republicans “now live in the worst of both worlds -- with nothing to show for seven years of campaign promises, even though dozens of vulnerable lawmakers cast votes that could leave them exposed to attacks from Democrats. . . . Republicans have continually failed to coalesce around an alternative — vividly demonstrated by the dramatic failure of the 'skinny repeal' on the Senate floor early Friday morning. They appear trapped in the fallacy of sunk costs: Having invested so much political capital in the ACA’s repeal, they cannot possibly abandon it.”

Former McConnell chief of staff Josh Holmes, a Republican strategist who often reflects his former boss's views, told the Post that Republicans should “Quarantine it. You can let it destroy your entire agenda and your entire party as a result of inaction by continuing to dwell on something that, frankly, they’ve proven unable to do.”

FDA delays rules that would restrict electronic cigarettes, and suggests it might endorse them as an aid to stop smoking

Teenager and e-cig (Photo via
Campaign for Tobacco-Free Kids)

"Electronic-cigarette makers won a major reprieve on Friday when the Food and Drug Administration delayed regulations that could have removed many of their products from the market and opened the door to endorsing e-cigarettes as a means to get smokers to quit," Sheila Kaplan reports for The New York Times.

In an interview, FDA Commissioner Scott Gottlieb, a physician, "sounded notably more open to e-cigarettes than many other federal public-health officials, who have opposed the devices as a gateway to nicotine addiction and eventually to the smoking of tobacco cigarettes," Kaplan writes. Though Gottlieb "said he was concerned about children’s use of e-cigarettes and would consider regulating flavors designed to appeal to them, he also noted the potential benefits to addicted cigarette smokers of products capable of delivering nicotine without having to burn tobacco."

"The announcement thrilled the e-cigarette industry, which was facing a deadline of next year for makers to seek approval to sell any product that entered the market after Feb. 15, 2007," Kaplan reports. However, in a conference call with reporters, Gottlieb said encouraged e-cig makers who want to promote the product as a smoking-cessation aid to consult with the FDA about approval of such a pitch. “We still have to figure out if they are a way to get people off combustible cigarettes. We don’t fully understand.” Researchers disagree on the issue, but one study found that teenagers who use e-cigs are more likely to become smokers, and teens are key targets for e-cig marketers.

Gottlieb's announcement that he would delay e-cigarette rules was included in the rollout of his plan to reduce U.S. tobacco deaths, which total about 480,000 a year, including about 9,000 in Kentucky. "That strategy will include steps to push makers of tobacco cigarettes to reduce the levels of nicotine in their products to make them less addictive," Kaplan writes.

"Gottleib said the FDA will redouble its efforts to protect children from products that contain nicotine, including e-cigarettes, and will pursue regulations of flavored tobacco products designed to appeal to them," Kaplan reports. "E-cigarettes come in many fruit and alcohol flavorings to appeal to 'vapers' of all ages, with names like Tutti Frutti and Cupcake." More teenagers use e-cigs than smoke tobacco, but a survey last year found that e-cig use among Kentucky high-school sophomores had declined.

McConnell's 'skinny repeal' bill is defeated, with John McCain casting the key vote

As Sen. Mitch McConnell watched, Sen. John McCain turned thumbs down and voted "no" on the bill.

UPDATE, 1:30 a.m. July 28: Three Republicans voted against the bill: Lisa Murkowski of Alaska, John McCain of Arizona and Susan Collins of Maine. The bill's 51-49 defeat pulled the plug, for now, on Republican efforts to repeal and replace President Obama's signature law.

Collins had long opposed McConnell's bills. Murkowski feared the effects they would have in her state, and like Collins she voted against the motion to start debate earlier in the week. But it was McCain who cast the most important vote, because if he had voted yes, Vice President Mike Pence would have broken the tie (as he did on the start-debate motion) and sent the bill to the House. UPDATE: In statements Friday, McCain said the bill didn't lower costs or improve care and called the chamber's inability to craft wide-ranging legislation "inexcusable," The Associated Press reports. "He said Democrats and Republicans should write a bill together," in contrast to its passage in 2010 and its attempted repeal.

"This is clearly a disappointing moment," McConnell said in a speech after the vote. He said most Republicans "kept our commitments. We worked really hard . . . trying to achieve a consensus and go forward. . . . I regret that our efforts were simply not enough, this time." He challenged Democrats to offer alternatives, but said "Bailing out insurance companies without any thought of reform is not something I want to be part of." For McConnell's full speech, click here.

Democratic Leader Chuck Schumer of New York pointed to the speech McCain had made upon his return to the Senate to vote to start debate, calling for "regular order" and a bipartisan solution. UPDATE: Friday morning, Schumer said Republicans shouldn't blame McConnell for their failure to pass a repeal bill, because they are so divided on the issue.

Senate Majority Leader Mitch McConnell introduced what has been generally dubbed his “skinny repeal” of the Patient Protection and Affordable Care Act late Thursday, "setting up a cliffhanger vote slated for midnight," The Washington Post reports.

McConnell's bill would repeal the law requiring almost all Americans to have health coverage or pay a tax penalty, "and suspend for eight years the mandate that firms employing 50 or more workers provide insurance," the Post reports.

It would "eliminate funds for preventive health care provided under the 2010 law and prohibit Medicaid beneficiaries from being reimbursed for Planned Parenthood services for one year," the Post reports. "Instead, the bill dictates the federal funding that would have gone to Planned Parenthood would go to community health centers. It would end a 2.3 percent tax on medical device manufacturers for three years."

Perhaps significantly for Kentucky, the bill would give states more flexibility in running Medicaid, the program that covers almost a million and a half Kentuckians, about 470,000 of them under then-Gov. Steve Beshear's 2014 expansion of the program.

McConnell is touting the bill as the only way to continue the process of repealing and replacing the ACA, by getting the bill to the House, which passed its own bill in May. The House could pass the bill and send it to President Trump; it could pass another version, which is unlikely; or it could reject the Senate bill, prompting a House-Senate conference committee that could write a whole new bill that would not be subject to amendment in either chamber.

Several Republican senators sought assurances that passing McConnell's bill would lead to a conference. House Speaker Paul Ryan gave no guarantees but said that was his hope.

After introducing his legislation, McConnell gave this speech:

“The legislation I just laid down is called the Health Care Freedom Act, and it restores freedom to Americans that Obamacare took away. It does so in a number of ways.

“First, the Health Care Freedom Act repeals the core pillars of Obamacare. It eliminates the so-called individual mandate that forces many Americans to buy Obamacare insurance they don’t want, can’t afford, or can’t use — and taxes those who don’t. It also repeals the employer mandate that cuts hours, take-home pay, and job opportunities for workers.

“Second, the Health Care Freedom Act provides significant new flexibility to states. The Health Care Freedom Act gives states just the kind of flexibility they need to implement reforms that provide more options for consumers to buy the health insurance they want. These reforms also help make insurance more affordable and flexible, so it’s something Americans actually want to buy.

“Finally, the Health Care Freedom Act frees Americans from Obamacare in several other ways too. It provides three years of relief from the medical device tax that increases costs, hurts innovation, and has drawn significant criticism from both sides of the aisle. It expands for three years the contribution limits to health-savings accounts so Americans can better manage their health costs and pay down more of their medical expenses, like prescriptions, with pre-tax dollars.

“This legislation will also prioritize funding for women’s health through community health centers instead of large abortion providers and political organizations.

“The American people have suffered under Obamacare for too long. It’s time to end the failed status quo. It’s time to send legislation to the president that will finally move our country beyond the failures of Obamacare. Passing this legislation will allow us to work with our colleagues in the House toward a final bill that can go to the president, repeal Obamacare, and undo its damage. I urge everyone to support it.”

1 in 12 Ky. high-school sophomores in 2016 poll said they'd attempted suicide in previous year; prevention efforts increase

By Melissa Patrick
Kentucky Health News

A 2016 survey found that 8.2 percent of Kentucky's high-school sophomores – about one in 12 – said they had attempted suicide at least once in the previous 12 months. That may seem high, but the national rate is even higher: 9.4 percent.

"We need to take that seriously," Dr. Julie Cerel, a psychologist and professor at the University of Kentucky College of Social Work and president of the American Association of Suicidology, told Kentucky Health News.

The state is stepping up its efforts to prevent suicide among teenagers, said Patti Clark, the state's suicide-prevention coordinator.

"Any number of students that attempt suicide is too many," Clark said. "For us, that indicates that we have kids who have unidentified issues and they are not receiving appropriate care. They are not being connected to resources that can help them through the rough parts of their life."

The biennial "Kentucky Incentives for Prevention" survey is given to students across the state in even-numbered grades starting in the sixth grade, but the official report says it only offers statistics from 10th graders, since these are the most likely indicators for high-school students. The survey primarily assesses alcohol, tobacco and other drug use, but also looks at suicide and other high risk behaviors.

The 2016 poll includes information from about 28,000 students in 149 of the state's 173 public school districts, but did not include the state's two largest districts. In addition to the Jefferson and Fayette county schools, Warren, Meade, Morgan, Laurel and Martin counties did not participate.

The survey found that 15.4 percent of Kentucky's sophomores reported having suicidal thoughts within the previous year. The rate was higher in eight of the state's 14 regions than it was in 2014, the first year the survey asked questions about suicide.

Beyond thinking about suicide, how many 10th graders made a plan about how they might kill themselves? 12.5 percent. The rate in seven of the 14 regions was higher than in 2014.

Ky. Incentives for Prevention Survey map (click on it for a larger version)

The statewide suicide-attempt rate of 8.2 percent was about the same as in 2014, but was higher in eight of the 14 regions. The highest rates were in three Western Kentucky regions: Four Rivers (9.3 percent), Pennyroyal (10.4 percent) and River Valley (9.2 percent) and a Northern Kentucky region comprising Bracken, Fleming, Mason and Lewis counties (9.6 percent).

Why do teens consider or try suicide?

Cerel said increased media information about suicide, both fictional and real, could be a reasons for the number of reported suicide attempts among the state's 10th graders because this exposure "might make teens more likely to admit they've had these thoughts and experiences."

Need for rural mental-health professionals is shown in full-time equivalents.
Counties not shown had surpluses of such professionals in 2012. (Kentucky
Health Care Workforce Capacity Report for state by Deloitte, 2013)

She added that the state's shortage of mental-health-care providers may also contribute to the number of teen suicide attempts in the state. The federal government estimates that as of December 2016, Kentucky had only 56 percent of the providers it needed.

That means many Kentuckians have to wait three to six months to see a mental-health-care provider, Cerel said, adding such a wait is a long time in the life of a teen who is sad or depressed – about one quarter of the school year.

"What does it mean for say a ninth-grade girl to be out of her peer group for three to six months because she is so depressed she can't function? Everything moves on past her," Cerel said. "So kids just aren't – all Kentuckians, actually – aren't getting access to appropriate mental-health services that could really lead to decreased suicide."

Cerel said the provider shortage is even worse for teens because many providers and pediatricians are reluctant to use medications to treat young people who are depressed. The American Association of Suicidology, which Cerel heads, says depression is present in at least half of all suicides.

Cerel also suggested that the state's opioid epidemic has likely played a role in the number of Kentucky's teens who have attempted suicide: "I would assume that that would be highly correlated."

What is Kentucky doing about it?

Clark said the state requires all middle- and high- school students receive some type of suicide-prevention information by Sept. 1, and every teacher or otherwise certified employee is supposed to participate in at least two hours of suicide prevention training every school year. But the implementation of these programs vary from school to school, she said.

Clark's office is rolling out a new suicide-prevention program called "Sources of Strength" in 100 schools across the state in the fall. She said 60 schools have already signed up to participate.

The Sources of Strength website says it is an evidence-based program that builds resiliency to suicidal thoughts, and touches on related issues such as substance abuse and violence through peer-led messaging campaigns that focus on "hope, help and strength."

"The thing about Sources is that it is peer-led, so it becomes the student's process," Clark said. "They get to make the change. Evidence does show that peer-led programming done correctly – meaning that the kids are not just a seat at the table, but they are truly given the power to do what they need to do and are equipped to do it in the right manner – really can make a difference. . . . We are excited about where this can go."

The state suicide-prevention program already provides technical training and assistance to schools, with evidence-based programs, Clark said, as well as "gatekeeper training," which teaches people in the community how to recognize the warning signs of suicide and how to get help for someone in crisis.

Clark's office also runs the "Kentucky Initiative for Zero Suicide" program, which trains mental-health-care providers – both practicing and those who are still in school – how to assess, treat and prevent suicide.

Clark said she and her staff don't know why so many Kentucky students contemplate, plan or attempt suicide. In a search for answers, they have scheduled meetings with in-patient psychiatric nurses and conducted a series of focus groups with directors of local schools' Family Resource & Youth Services Centers to find out what students are telling them about it.

"We are looking at ways to increase our data, to increase our surveillance opportunities, to find that information so that we can target our prevention efforts," Clark said.

What can parents do?

Cerel said parents should not hesitate to tell a child they are concerned about them if they think their child is contemplating suicide, and offer to get them help. She said FRYSC staff,  school counselors and pediatricians are great resources for both kids and parents.

"I think they cannot be afraid to ask directly about it," she said. "Say, 'I'm really worried about you, are you thinking about killing yourself?' It's not like that is going to put any ideas in anyone's head." She said there is "absolutely no evidence" to support that mistaken belief.

Cerel said it's important for parents to take any threat of suicide seriously, regardless of the circumstances, and not think it is "merely a cry for attention. It's a cry for attention because they are feeling so awful that suicide might be the only way they think they can change their circumstance."

Clark said that it's important for parents to store firearms separately from the ammunition, which is required by a state law that is often ignored.

"Especially for youth, the time from the decision to die to actually attempting death may be as short as five minutes," she said. "If there is enough of a barrier between that child and that weapon, you may have the opportunity to save that child's life. So simply storing your gun and your ammunition separately could make a big difference in those numbers."

Suicide is the second leading cause of death among Kentucky's teens and young adults, according to the American Foundation for Suicide Prevention.

Experts say these are warning signs of suicide:

• Talking about suicide
• Making statements about feeling hopeless, helpless or worthless
• A deepening depression
• A preoccupation with death
• Taking unnecessary risks or exhibiting self-destructive behaviors
• Out of character behaviors, including changes in sleep habits or appetite
• Increasing the use of alcohol or drugs
• A loss of interest in the things one cares about
• Visiting or calling people one cares about
• Setting one's affairs in order
• Giving prized possessions away

If you have any of these warning signs, or someone you know is exhibiting any of them, help is available at the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Another resource is the Crisis Text Line: Text HOME to 741-741.

8/3/2017: This article has been updated to reflect that storing firearms separately from ammunition is not required by Kentucky state law. 

Senators seek a guarantee that the House won't pass the bill McConnell may have them pass; they want to keep talks going

Kentucky Health News

A stripped-down version of a health-insurance bill won't pass the Senate unless House Speaker Paul Ryan guarantees that the House will take the issue to a House-Senate conference committee and not pass the so-called "skinny repeal" into law.

Republican Sens. Lindsey Graham, Ron Johnson and John
McCain sought assurances. (Associated Press photo by Cliff Owen)

That became clear late Thursday afternoon, when Republican Sens. John McCain of Arizona, Lindsey Graham of South Carolina, Ron Johnson of Wisconsin and Bill Cassidy of Louisiana said they would not vote for the limited bill without such a guarantee. Since Democrats are solidly against such a measure and 52 of the 100 senators are Republicans, three "no" votes would kill the bill.

"The skinny bill as policy is a disaster," Graham told reporters. "The skinny bill as a replacement for Obamacare is a fraud." He said Senate Majority Leader Mitch McConnell has told him that Ryan "prefers to go to the conference" and "intends to go to the conference."

Several hours later, Ryan issued what The Washington Post called "a measured statement," with this key passage: “If moving forward requires a conference committee, that is something the House is willing to do. The House remains committed to finding a solution and working with our Senate colleagues, but the burden remains on the Senate to demonstrate that it is capable of passing something that keeps our promise.”

McCain replied, “I would like to have the kind of assurances he didn’t provide.” But Graham said he would trust Ryan, The New York Times reported.

After Ryan's statement, McConnell offered limited legislation that would repeal the individual and employer mandates and the preventive health-care funding of the Patient Protection and Affordable Care Act, and suspend for three years its tax on medical devices. It would also give states more flexibility in operating their Medicaid programs. McConnell has been unable to get 50 votes to pass a more comprehensive bill. Vice President Mike Pence's tie-breaking vote earlier this week was only to put a bill on the floor and start debate.

"McConnell made one last frantic plea to his Senate Republican members to advance the party’s scaled-back Obamacare repeal, assuring them at a private lunch that the vote is merely aimed at getting to conference with the House rather than preparing it to land on President Donald Trump’s desk," Politico reports. "But Graham said McConnell could not offer a promise that Ryan would do so." That echoed concern among Republican senators that the House was adopting a procedure that would allow it to "quickly take up and pass" the bill.

Republicans "could try to salvage a bigger repeal-and-replace bill in House-Senate negotiations," Dylan Scott of Vox writes. "That would put Medicaid back on the table for cuts and surely lead to bigger coverage losses than skinny repeal alone. The uncomfortable truth for these Republican senators is they've been trying to do the latter for the past two months and they haven't been able to do it. It's not clear how adding the House to the mix could possibly help."

Any bill reported by a House-Senate conference committee would go back to both houses for approval and would not be subject to amendment.

"So in a matter of hours, we could be heading into drawn-out conference negotiations — or skinny repeal could be the law of the land," Scott writes. To show how divided Republicans are, he relates what Johnson and Sen. Rand Paul of Kentucky told him in the past two days. "Paul supports skinny repeal and wants the repeal-and-replace bill to stay dead. Johnson feels very differently."

Here's what Paul said about the idea of passing skinny repeal in order to take the issue a conference committee:

"I'm gonna advocate that if we can get some repeal, that we just send it to the House for approval because I think if it goes to conference committee, it's gonna get built back up into the monstrosity that we just voted down. If we end up with a $300 billion insurance subsidy fund, I think conservatives will vote against that also. . . . If it goes to conference committee and it explodes in its breadth and expense, they're gonna have trouble getting the votes."

And here are Scott's quotes from Johnson, who was the last senator to vote to start debate:

"It's sad. It's very sad. It's very sad." Asked if it is better than nothing, he replied, "If I vote yes, it's certainly saying it's better than the status quo, which is awful. You keep coming back to that. No matter how disappointing this is, how frustrating it is, you come back to the fact that these markets are collapsing."

Johnson said one Wisconsin family had to repay $15,000 in ACA subsidies because their income ended up being higher than they expected. "I don't see anything in any of these bills that really addresses those forgotten men and women," he said.

Here is Vox's chart of the Congressional Budget Office estimates of annual growth in the uninsured population as potential results of each major bill that has been debated:

Paul gives McConnell his vote to open health-insurance debate, then votes against his repeal-and-replace bill; more votes coming

Sens. Mitch McConnell of Kentucky and John
Cornyn of Texas after the vote to start debate
(Washington Post photo by Oliver Contreras)

Kentucky Health News

Senate Majority Leader Mitch McConnell got just the votes he needed to start debate on a health-insurance bill Tuesday, but that night Republicans' "most comprehensive plan to replace President Barack Obama’s health law fell far short of the votes it needed," The New York Times reported.

The latest version of McConnell's Better Care Reconciliation Act needed 60 votes to overcome a parliamentary objection. It got 43, with 57 senators opposing it.

The tally "was an ominous sign for Republican leaders still seeking a formula to pass final health-care legislation this week," the Times' Thomas Kaplan and Robert Pear wrote.

At mid-afternoon, McConnell scored a victory that had eluded him for weeks, getting 50 Republican votes to proceed with debate on a bill, plus Vice President Mike Pence's vote to break a tie. Two Republicans and 48 Democrats voted not to proceed.

Sen. Rand Paul, who had said he would vote to proceed only on a "clean repeal of Obamacare," voted with his Kentucky seatmate after weeks of disagreement. Paul had tweeted, “This morning, @SenateMajLdr informed me that the plan for today is to take up the 2015 clean repeal bill as I’ve urged,” Paul this morning. “If that is the plan, I will vote to proceed to have this vote. I also now believe we will be able to defeat the new spending and bailouts.” Later, Paul voted against McConnell's bill.

UPDATE, July 26: The Senate voted 55-45 Wednesday afternoon against a Paul amendment that would have repealed Obamacare but delayed the effective date for two years. Among those voting no was Sen. Lamar Alexander, R-Tenn., chair of the Senate health committee.

Earlier, McConnell had secured the votes of Sens. Dean Heller of Nevada, Rob Portman of Ohio and Shelley Moore Capito of West Virginia, who have been concerned about McConnell's plan to phase out expanded funding of Medicaid and scale back the entire program. Kentucky also has hundreds of thousands of people on Medicaid through the expansion.

The three senators "hoped McConnell could be persuaded to add $100 billion in spending aimed at blunting those cuts, but leadership was caught between them and fiscal conservatives," Politico reported. "In front of McConnell and the rest of the caucus, [President] Trump told Republican senators that 'We’re going to add this money to the bill,' according to two sources familiar with the matter."

The last vote came from Sen. Ron Johnson of Wisconsin, who had criticized McConnell for telling moderates that the Medicaid cutbacks would never come to pass. At McConnell's desk on the Senate floor, "The two engaged in a tense, 10-minute face-to-face talk. McConnell’s face turned increasingly red, and the GOP leader threw up his hands multiple times," Politico reported.

But after Sen. John McCain returned from surgery and a brain-cancer diagnosis and voted yes, Johnson was on the spot. "Left with the option of being the Republican who killed Obamacare repeal or the one who saved it, the Wisconsin senator quickly flipped a thumbs-up into the air to vote yes," Politico reported. All 48 Democrats then voted no, causing the tie that Pence broke.

"That McConnell even got to this point was remarkable," wrote Politico's Jennifer Haberkorn, Seung Min Kim and Burgess Everett. "Just a week ago, the GOP’s repeal-and-replace effort was practically declared dead, as the GOP leader himself said it was 'pretty clear' there weren’t 50 votes for a health-care bill."

"In the end, it was McConnell’s binary choice argument that reeled in the 50 votes. McConnell relentlessly laid out his reasoning . . . a vote against even debating Obamacare repeal is a vote to keep it in place."

McCain's return gave McConnell momentum and made the difference, but in an emotional floor speech he urged Republicans to work with Democrats on a solution to the issue, "something that my dear friends on the other side of the aisle didn’t allow to happen years ago."

Politico reported, "The Arizona senator left open the question of whether he would help his fellow Republicans eventually pass a bill now that debate has begun. And though clearing Tuesday’s procedural hurdle was almost certainly McConnell’s most hard-fought victory of the year, passing legislation is another matter."

The debate will be mainly on a series of amendments, few if any of which are likely to pass. "The end goal is likely a stripped-down repeal of Obamacare’s individual and employer mandates and the law’s medical device tax, perhaps with more add-ons. The GOP will now pass whatever can garner 50 votes, no matter how scaled-back McConnell’s ambitions of repealing Obamacare 'root and branch' have become," Politico reported.

"Their hope is to get something to the House and get it off the Senate’s plate. With any luck, senators say, they will end up in a bicameral conference and finish the job later this year. And now that McConnell has won a vote to proceed to an uncertain outcome, no one is counting him out."

UPDATE, July 26: Obamacare supporters warned that a House-Senate conference could revive the repeal-and-replace idea. Republican moderates would find it more difficult to vote against a repeal-and-replace bill coming out of a conference because it would not be subject to amendment. “It’s either take it or leave it,” Jacob Leibenluft, of the liberal Center on Budget and Policy Priorities, told Tony Pugh of McClatchy Newspapers. “Either that bill passes or those senators [who vote against it] will be held responsible for preserving the Affordable Care Act in the minds of their Republican voters.”

The Blue Cross Blue Shield Association said the individual mandate should not be repealed without something to replace its role in stabilizing insurance markets. "We need strong incentives for younger, healthier people to obtain coverage and for everyone to stay covered year-round," the insurers said in a statement. There is no effective replacement for the mandate, Sherry Gleid and Adlan Jackson write for The Commonwealth Fund.

UPDATE, July 27: Ten governors, five from each party, told McConnell in a letter that they opposed the stripped-down bill, dubbed "skinny repeal," and that Congress should focus on stabilizing insurance markets.

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.

Annual Bost Health Policy Forum to be held in Lexington Sept. 25; focus will be on "Kentucky's Substance Use Crisis"

The 2017 Howard L. Bost Health Policy Forum, "Kentucky's Substance Use Crisis: Solutions and Strategies" will have as its keynote speaker Sam Quinones, author of the book Dreamland, which chronicles the rise of prescription opioid abuse and subsequent addiction across the nation. Much of the book focuses on Portsmouth, Ohio, just across the river from Kentucky.

"Quinones' narrative is a compelling account of the opioid crisis that took 1,400 lives in Kentucky last year," Ben Chandler, Foundation for a Healthy Kentucky president and CEO, said in the news release. "Kentucky's experience with both prescription and illicit opioids has been more severe and longer-lived than in most other states. Quinones and other presenters will help us better understand how we got to where we are today, how to climb our way out of this crisis, and the policy changes that can prevent this from happening again."

The annual forum is sponsored by the foundation with support from Gilead Sciences Inc., a research-based bio- pharmaceutical company, in memory of Dr. Howard L. Bost, who helped create Medicare and Medicaid, developed the Appalachian Regional Hospital system, improved mental-health services in Kentucky and created the vision for the foundation.

It will be held at the Marriott Griffin Gate Resort in Lexington on Monday, Sept 25. Attendance is free, but registration is required. Click here to register.

The forum will also feature a series of TED-style talks and afternoon breakout sessions that will explore where Kentucky stands related to the opioid epidemic; how evidence-based policy can work as a tool to address the social, economic and health impacts of opioid addiction; and prevention and intervention strategies.

Interactive map gives estimated premiums under latest Senate health-insurance bill, by age, income and county

The fate of health-insurance legislation in the Senate remains very much up in the air, but the Kaiser Family Foundation has updated its interactive, county-level map showing how the latest version of the Better Care Reconciliation Act would affect premiums for silver-level Obamacare plans, the type most commonly purchased with tax-credit subsidies. The figures are the estimated premium in 2020 after tax credits. Pop-up tables for each county also show premiums for cheaper bronze-level plans, the amounts of tax credits (or savings from putting pre-tax income into health-savings accounts), and the change from current law. Here's a screenshot of the map for a 40-year-old Kentuckian with a yearly income of $40,000:

The map can be adjusted for age (27, 40 and 60) and income (mostly in in $10,000 increments). The version above is for 40-year-olds with income of $40,000 a year. Here's one for 60-year-olds making $60,000, showing that premiums for them would go up in every county:

To show how the individual county estimates are displayed, here's a screenshot of estimates for a 40-year-old with $40,000 annual income in Grayson County (click on it for a larger version):

Nursing professor at Pikeville moves up to dean

Karen Damron

Karen Damron, an associate professor in the Elliott School of Nursing at the University of Pikeville, is the new dean of the school.

Damron was raised in El Paso moving to Pikeville in 1993, and has taught full-time at the university since 1998, a news release said. Before becoming an educator, Damron worked full-time as an RN in obstetrics and neonatal intensive care in hospitals in Texas and Maine. She earned her Ph.D. from the University of Kentucky, an M.S. from Bellarmine University and a B.S. from the University of Texas at El Paso, all in nursing. She and her husband, Larry, live in Pikeville and have four sons and three grandchildren.

In 2010, the Mellon Foundations named Damron a fellow to the Salzburg Seminar in Austria. She earned UPike’s William Wade and Helen Record Walker Teaching Excellence Award in 2014 and was awarded a pre-doctoral faculty fellowship by the Appalachian College Association for the 2015-2016 academic year. Her research interests include perinatal smoking and factors that impact a woman’s smoking status in pregnancy.

As health-insurance vote looms, McConnell's path to immediate success is narrowed

Kentucky Health News

UPDATE, 3:08 p.m. July 25: The Senate voted 51-50, with Vice President Mike Pence breaking the tie, to open debate on health insurance, via the bill passed by the House. After the vote, Senate Majority Leader Mitch McConnell introduced an amendment as a substitute to the House bill, to be titled the Obamacare Repeal Reconciliation Act. (UPDATE, 11 p.m.: That measure failed, 57-43, which was 17 votes short of the 60 it needed to pass.)

Republican Sens. Susan Collins of Maine and Lisa Murkowski of Alaska voted no and were the exceptions to the party-line vote. Kentucky Sen. Rand Paul, who had been a holdout with them, voted with the majority. Paul had tweeted earlier, “This morning, @SenateMajLdr informed me that the plan for today is to take up the 2015 clean repeal bill as I’ve urged,” Paul this morning. “If that is the plan, I will vote to proceed to have this vote. I also now believe we will be able to defeat the new spending and bailouts.”

As Senate Majority Leader Mitch McConnell moved toward a climactic vote Tuesday on health insurance, the Senate parliamentarian made it more difficult for him to maneuver by saying that some measures would require more votes to pass.

Sen. Mitch McConnell (Photo
by Brendan Smialowski, Agence
France-Presse via Getty Images)

McConnell is trying to pass a bill under budget-reconciliation rules, which disallow the filibusters that require 60 votes to stop. His goal is 50 votes and a tie-breaking vote by Vice President Mike Pence. But the parliamentarian has ruled that several points don't qualify under reconciliation because they aren't related to the budget, taxes or spending.

"In a blow to the insurance industry, the parliamentarian has advised that two key market-stabilization provisions in the bill would be against the rules," Nathaniel Weixel of The Hill reports. "First, the legislation can't appropriate the cost-sharing reduction subsidies insurers rely on to keep premiums and deductibles low; it can only repeal them. Additionally, a 'lockout' provision requiring consumers with a break in coverage to wait six months before buying insurance also violates the rules, according to the guidance." Also nixed was a repeal of the law limiting insurance company profits.

The cost-sharing subsidies have been in doubt because Congress has not specifically appropriated money for them, and the Trump administration has suggested that it might stop them -- a move that could further destabilize insurance markets.

Other provisions found wanting "include policies important to conservatives, such as restrictions on tax credits being used for insurance plans that cover abortion," The Hill reports. "Language in the bill defunding Planned Parenthood for a year also violates budget rules, according to the parliamentarian. That guidance is sure to anger anti-abortion groups who backed the bill specifically because of those provisions."

McConnell could revise the language to get it approved, or conservatives could ask the Senate to overrule the parliamentarian, but in the past McConnell has thrown cold water on that idea.

"The parliamentarian has also not yet ruled on a controversial amendment from Sen. Ted Cruz (R-Texas) that would allow insurers to sell plans that do not meet Obamacare regulations," The Hill reports. "If that provision were struck, conservative support for the bill would be in doubt."

The parliamentarian could also complicate any McConnell efforts to get votes by inserting special funding that would help states represented by holdout senators.

American Health Policy Institute President Tevi Troy, a former deputy HHS secretary in the George W. Bush administration, told The Wall Street Journal that Republican leaders' work on the legislation is "entirely political," about what can get enough votes to pass, not about what the best policy would be.

It remains unclear whether McConnell can even get the votes to take up a bill, much less pass anything resembling the one he has been trying to pass without success.

Sen. Rand Paul (Getty Images)

His more conservative Kentucky seatmate, Rand Paul, said on CNN's "State of the Nation" Sunday that he would not vote to take up McConnell's bill, which he called a "monstrosity" with a "pork fest" of subsidies for insurance companies.

Paul said he would vote to take up a "clean repeal" bill, which McConnell has offered as an alternative. That measure would not become effective for two years, giving Congress time to figure out a replacement for the 2010 Patient Protection and Affordable Care Act.

Either bill could be a vehicle to pass something different, perhaps even a limited, bipartisan measure to stabilize insurance markets. McConnell said last month that would be the alternative if Republicans couldn't pass a bill on their own, but more recently has cast doubt on that option.

"In the absence of internal consensus on health reform, other GOP lawmakers are leaning toward a more bipartisan approach," Brianne Ehley reports for Politico.

McConnell told reporters at the White House following a lunch with President Donald Trump and almost all of the Republican senators, "I think we have two options here. I think we all agree it's better to both repeal and replace. But we could have a vote on either, and if we end up voting on repeal only, it will be fully amendable on the Senate floor and if it were to pass without any amendment at all there's a two-year delay before it kicks in . . . so the takeaway from what I'm telling you is no harm is done from getting on the bill."

If no bill is taken up, "We’ll go back to the drawing board and get a bill up,” Senate Republican Conference Chair John Thune of South Dakota said on "Fox News Sunday." “We are going to vote to repeal and replace Obamacare. It’s not a question of if, it’s a question of when.”

Paul agreed, telling CNN's Jake Tapper, “We can do this for quite a while.”

Meanwhile, Trump criticized Paul for his frequent TV appearances. Privately, White House officials criticized McConnell for not getting the votes for a bill that Trump and Republicans have long promised, while Republican senators "say Trump failed to provide any meaningful political momentum for the prized measure," Alex Bolton reports for The Hill. "Tensions between Trump and Senate Republicans have been a theme of the months-long effort to win passage of the healthcare legislation." Trump has been sending mixed messages lately, The Associated Press reports.

McConnell "is getting pummeled in the press," Fox News media reporter Howard Kurtz writes, rounding up much of the critical coverage and commentary. But he says McConnell "was essentially put in an impossible position" that even "Master of the Senate" Lyndon B. Johnson couldn't have played well.

"I doubt that even LBJ, in his Senate arm-twisting days, could have pushed through a bill so unpopular with the public and such anathema to two competing factions," Kurtz writes. "It’s easy to blame tactics when everyone does their tick-tocks, and the Kentucky senator may have made some missteps. But the bill ultimately failed because of the substance: it was too weak at changing Obamacare for the most conservative GOP senators and too draconian in reducing coverage for the most moderate ones. And the majority, with 52 members, could afford to lose just two votes against united Democratic opposition. . . . There’s a reason the Republicans don’t have the votes, and it’s not Mitch McConnell."

Protesters ramp up activity against state's only remaining abortion clinic, prompting national news coverage

Protesters at clinic (AP photo by Dylan Lovan)

The battles over Kentucky's only remaining abortion clinic have prompted national stories about the prospect that the state could become the only one with no place to get a legal abortion.

"Both sides in the abortion fight raging in Kentucky agree on one thing: The stakes are as high as ever," reports Bruce Schreiner, a Louisville-based writer for The Associated Press. He details Republican Gov. Matt Bevin's "licensing fight" with EMW Women's Surgical Center in Louisville and the start of organized protests there by Operation Save America, "a Christian fundamentalist group."

"The group's leaders state their purpose unequivocally: to rid Kentucky of its last abortion clinic," Schreiner reports. "Some of the group's followers were arrested during a protest outside EMW in the spring. The group has said it won't use those same tactics in the coming days, but a federal judge on Friday ordered the creation of a 'buffer zone' to keep protesters out of an area in front of the clinic. The pre-emptive move was requested by federal prosecutors to prevent protesters from blocking access to the surgical center."

Anna Werner of  CBS News reports that the group plans to protest at "other locations, including the doctors' homes." The clinic has been the scene of protests since soon after it opened in the early 1980s, but "We have never been under siege like this," Dr. Ernest Marshall, a co-founder of the clinic, told AP. "We have never had any question as to whether we would exist."

Study: 33% of dementia cases could be prevented by avoiding certain risk factors, including 9% by reducing mid-life hearing loss

By Melissa Patrick
Kentucky Health News

One-third of the world's dementia cases might be prevented if people avoided nine very different risk factors in three stages of life, according to experts speaking at the 2017 Alzheimer's Association International Conference.

The factors, by age group, are: going to school beyond age 15; managing high blood pressure, obesity and (this was something new) hearing loss between 45 and 65; and reducing smoking, depression, physical inactivity, diabetes and social isolation in later life.

The researchers said resolving those factors could reduce dementia cases by 33 percent. In comparison, they said that finding a way to eliminate the major genetic risk factor for dementia, called apolipoprotein E (ApoE), would prevent only 7 percent of cases.

The study, published in The Lancet, the leading British medical journal, brought together 24 international experts to review existing research. They presented their findings at the Alzheimer's conference in London, England, Robert Preidt reports for HealthDay.

"Acting now will vastly improve life for people with dementia and their families, and in doing so, will transform the future of society," lead author Gill Livingston, a professor at University College London, said in a news release.

About 47 million people have dementia, and the number is estimated to nearly triple by 2050.  An estimated 69,000 Kentuckians were diagnosed with Alzheimer's disease in 2016, according to the Alzheimer's Association.

The researchers said targeting three of the risk factors would have the most impact on dementia prevention. One of them, reducing hearing loss between 45 and 65, had not been quantified before.

The researchers estimated reducing hearing loss in mid-life could cut the number of dementia cases by 9 percent. They don't yet know why hearing loss is a risk factor for dementia, but said it could lead to social isolation and depression, which are known to contribute to cognitive decline. They said more research is needed to see if hearing aids would reduce this risk.

Schooling beyond the age 15 would reduce the total number of dementia cases by 8 percent, the report estimated. The researchers said low education "is thought to result in vulnerability to cognitive decline because it results in less cognitive reserve," which Harvard Medical School describes as "your brain's ability to improvise and find alternate ways of getting a job done" and says is developed by a lifetime of education and curiosity.

The researchers estimated that stopping smoking later in life could reduce the number of dementia cases by 5 percent because quitting reduces neurotoxins and improves heart health, which then improves brain health.

Livingston told HealthDay that dementia is usually diagnosed later in life, but brain changes related to the disease develop years before the symptoms appear: "We believe that a broader approach to prevention of dementia which reflects these changing risk factors will benefit our aging societies and help to prevent the rising number of dementia cases globally."

Artificial sweeteners linked to long-term weight gain, higher body-mass index and risk of heart disease, but we don't know why

Epicurious.com

Artificial sweeteners are "dodgy" when it comes to weight management, and people who use them regularly have higher risks of developing cardiovascular disease and diabetes, and bigger body-mass indexes, a height-weight ratio that indicates obesity.

So say a group of international researchers who reviewed more than 30 studies about the long-term health effects of sugar substitutes, Cleve R. Wootson Jr. reports for The Washington Post. Their research, published in The Canadian Medical Association Journal, covered more than 406,000 people who said they used artificial sweeteners.

Researcher Meghan Azad of the University of Manitoba said that while the studies show a link between artificial sweeteners and body-mass index, “We need more evidence from better-quality studies to know for sure the cause and effect, but there does seem to be at least a question about the daily consumption of these drinks."

The U.S. market for sodas decreased by 0.6 percent between 2011 and 2016, Wootston notes, but "close to half of adults and a quarter of children consume artificial sweeteners every day, according to the Journal of the Academy of Nutrition and Dietetics."

The American Diabetes Association and the American Heart Association approved the use of artificial sweeteners in 2014, but Wootson says people have become increasingly suspicious of aspartame, sucralose and steviocide, (brand names: Equal, Splenda and Stevia, respectively) because studies have linked them to increased belly fat, and "bogus but widespread rumors that they led to things much worse."

The ADA's chief scientific medical and mission officer, William Cefalu, reviewed the study at the Post's request and also concluded that more studies are needed. "He said artificial sweeteners are still a good tool for diabetics trying to reduce carbohydrates and tightly manage their blood-glucose levels. But he stressed moderation, and agreed that more studies about the long-term effects of artificial sweeteners were needed — particularly on people with diabetes," Wootson writes.

Azad said the study found “nonnutritive sweeteners significantly associated with modest long-term increases” in body weight, BMI and waist circumference, which has been linked to a greater risk of heart disease and diabetes.

But she stressed that they still don't know why these associations exists, and noted that most of the studies focused on people who were working to lose weight or had other medical conditions.

Azad offered several possibilities for the link between artificial sweeteners and increased BMI, ranging from the sweeteners causing changes in gut bacteria to the possibility that people who are gaining weight for other reasons may seek out more artificially sweetened foods.

Meanwhile, she advises "consumers to not automatically assume artificially sweetened foods are the healthier alternative," Wootson writes.