Frankfort judge strikes down law requiring medical review of malpractice lawsuits; Bevin's office says he will appeal

A judge has ruled that a new law aimed at decreasing frivolous lawsuits and lowering malpractice insurance costs was unconstitutional, and he prohibited the state from enforcing it.

The Oct. 30 ruling by Franklin Circuit Judge Phillip Shepherd said the 2017 law is unconstitutional because it restricts the right of people to plead their cases in court by requiring that the cases be reviewed by a medical panel before proceeding, Deborah Yetter reports for The Courier- Journal. 

"The effect of the medical-review panel process is not the reduction of frivolous negligence claims, but rather, the erection of barriers to the court system," Shepherd's order said. "Those that cannot afford the additional delays and costs should not be prevented from pursuing their constitutional right to a 'remedy by due course of law.' "

The law, which took effect June 29, was touted as "the first step toward tort reform" by Gov. Matt Bevin when he signed it into law, Yetter reports. Bevin's office said it will appeal the decision. "We are confident medical review panels are constitutional," spokeswoman Amanda Stamper told Yetter.

Senate Minority Leader Ray Jones, D-Pikeville, a lawyer who has strongly argued against the law, told Yetter he expects the ruling to stand, calling it a "clear barrier to access to the courts."

Three articles published in The Journal of Rural Health show the importance of integrating oral health and primary-care medicine

By Melissa Patrick
Kentucky Health News

Three studies reported in the autumn edition of The Journal of Rural Health show different ways a regular health care provider can help patients get access to dental care, and all three articles say that integrating oral health and primary care would benefit patients.

The first study, using data from more than 26,000 participants in the 2012 Medical Expenditure Panel Survey, looked at whether having a "usual source of care" makes a difference in whether a person gets preventive dental checkups. A usual source of care, which researchers call a "USC," is a place where a person goes when he or she is sick or needs medical attention – not including an emergency room.

The study found that about 66 percent of individuals with a USC had a preventive checkup, while only 47 percent of individuals without a USC did.

Both rural and urban residents with a USC were 11 percent more likely to have at least one dental checkup per year. "This demonstrated that no matter where people live, having a USC was associated with a higher probability of having at least one preventive dental checkup," the article says.

However, the study also found that rural adults had "significantly lower odds" of getting an annual preventive dental exam that those living in urban areas – 51.5 percent vs. 63.4 percent, respectively.

The researchers said incorporating dental care into primary care "may help mitigate the challenges due to a shortage of oral health care providers in rural areas," and noted that previous research and the World Health Organization have recommended such integration.

The article offers an example of how this might work: "Primary care providers can be trained to provide regular dental screenings and oral health risk assessment, and oral-health care providers can help identify patients with increased risk for developing cardiovascular disease."

The article, "Preventive Dental Checkups and Their Association With Access to Usual Source of Care Among Rural and Urban Adult Residents," added that tele-dentistry and mobile dental clinics could be part of the solution to improve oral health access.

Preventive dental care is least likely in the South, where 58 percent of residents had a preventive dental service in the past year. Southern states, including Kentucky, have "a lower density" of health care providers, including dentists, the researchers noted.

They remind readers of the importance of annual dental exams: "Lack of preventive dental care can result in a higher prevalence of dental caries, periodontal disease, tooth loss, oral cancer, cardiovascular disease and other negative health outcomes, leading to a decreased quality of life."

Having usual source of care doesn't eliminate black-white disparities

The second study examined how having access to a USC affected the oral health of older adults, specifically looking at differences between African Americans and whites. It used data from more than 15,000 adults aged 50 and older from the national Health and Retirement Study.

The research also established that having a USC made dental care more likely, but the association between a USC and tooth loss in rural areas varied greatly by race, with blacks having more tooth loss than whites even if they had a USC.

The study found that 28 percent of rural blacks had lost all their teeth, compared to 18.7 percent of urban blacks, while 17.5 percent of rural whites had complete tooth loss, compared to 11.1 percent of urban whites.

The report found that both races in rural areas have substantially more tooth loss and fewer dental visits when compared to their racial counterparts in urban areas.

The same held true for dental visits, with 34.3 percent of rural blacks reporting having a dental visit in the previous two years, compared to 49.3 percent of urban blacks; 62.4 percent of rural whites had had a dental visit in the prior two years, compared to 73.5 percent of urban whites.

The study also showed sizable differences between the races in reports of a USC in both rural and urban areas. In urban areas, 88 percent of whites reported a USC, compared to 78 percent of blacks; in rural areas, 88 percent of whites reported having a USC, while only 70 percent of blacks did.

The report stressed that having a USC did not completely eliminate the differences in oral health between whites and blacks. It noted that even with a USC, older rural blacks appeared to have more tooth loss and fewer recent dental visits when compared to older rural whites.

"These findings may underscore continued disparities in community access to both health care and dental care and poorer quality of care for rural blacks," says then article, "The Role of Primary Care for the Oral Health of Rural and Urban Older Adults."

It reports that one in four adults age 60 and older have no natural teeth, "with blacks having significantly higher rates of missing teeth when compared to whites." It also found that Appalachia and the Mississippi Delta have higher rates of tooth loss than the U.S. population in general.

These regional disparities could be explained by "rapidly aging populations, a greater proportion of blacks, less fluoride in the water, and lower socioeconomic status" and "older rural populations, and particularly blacks, may also have had limited access to preventive dental care as children," the researchers write.

They conclude, "Access to primary health care was associated with improved oral-health outcomes, but it did not close the gap between whites and blacks in rural areas."

The researchers said an integration of primary and oral health care could particularly benefit older adults who smoke or have diabetes, which increases the risk of poor oral health. They also suggested that primary-care physicians need more oral-health education, and stressed the importance of new models of care, like the medical home, to better integrate geriatric dental care into the primary-care setting.

"These findings are important for public health because missing teeth may contribute to limited food choices, poorer nutritional intake, and lower quality of life," says the report.

Medical-dental referral networks help but aren't always dependable

The third article reports that collaboration between doctors and dentists works in rural areas.

The study looked at rural medical-to-dental referral networks. It involved 559 medical and dental professionals from 44 states who attended one of 10 continuing-education classes about collaboration. It also looked at whether rural health clinics, which get incentives to care for Medicaid and Medicare patients, but otherwise act a private practice, have different medical-to-dental experiences than other types of practices.

The study found that nearly half (48.7 percent) of the participants reported their medical-to-dental referral systems were dependable. A plurality (40.6 percent) said their referral system was bi-directional, meaning medical and dental practices  referred to each other; 25.9 percent reported systems that were one-directional, with medical referring to dental; 33.5 percent reported having no referral system.

The survey found no rural-urban differences. "Our study demonstrates that, in this motivated study population, medical-to-dental referrals can work well, even in rural areas," the researchers wrote.

They also found that accountable-care organizations, which work under a prevention-focused care model, were over five times more likely than rural health clinics to report dependable medical-to-dental referral systems. Federally qualified health centers, which "have long been identified as medical-dental integrators," were just over three times more likely than rural health clinics report dependable referral systems.

Practitioners with electronic health records and the ones who made referrals by way of a "warm hand-off or internal information exchange," which is typical of an ACO or hospital network, were the most likely to report they had a dependable referral system.

The report notes that the federal Health Resources and Services Administration has made recommendations on integration of oral-health and primary-care practices, but both the medical and dental participants reported dissatisfaction with communication between the professions, and better guidelines are needed, says the report.

The article points out that the Patient Protection and Affordable Care Act was written to support collaboration between health professionals through the use of electronic health records, patient-centered medical homes and accountable-care organizations. That said, the researchers said they were surprised that states that expanded Medicaid under the ACA did not report that they had a more dependable medical-to-dental referral system.

"This may reflect previous findings that increasing benefits coverage may not necessarily lead to increased dental-care utilization, especially if certain environmental, social, and economic characteristics are absent," the article says. "When enabling conditions such as reduced administrative burdens, improved oral-health prioritization, dental-care affordability, higher Medicaid reimbursement, and a better understanding of dental benefits by patients are present, effective utilization appears more likely to occur."

The study is titled "An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality."

At Pikeville building dedication, national optometry leader says new college will be a national leader in training of optometrists

UPike Health Professions Education Building

The University of Pikeville dedicated its newest facility, the Health Professions Education Building, Oct. 27. The building houses the school's new Kentucky College of Optometry, the only such college in Kentucky, and UPike’s growing nursing program.

“Our nursing students are enjoying their new space in the HPEB,” said Karen Damron, Ph.D., dean of the Elliott School of Nursing. “They utilize study areas that were not available prior to moving in the facility. In addition, the faculty offices are highly professional and conducive to meeting with current and prospective students. This new building will be key in the continued expansion of our nursing program.”

U.S. Rep. Harold “Hal” Rogers told more than 600 people at the dedication that UPike is helping close the gap on health disparities in Central Appalachia. “Today Central Appalachia has the highest rates of preventable blindness in the nation,” he said. “So what does UPike do? They build a state-of-the-art facility with the very best equipment, cutting-edge technology and a first-class team.”

The $72 million for the building came from grants by the U.S. Economic Development Administration and the Appalachian Regional Commission, and a low-interest stimulus loan from the Department of Agriculture’s Rural Development Administration, according to a university news release.

ARC Federal Co-Chair Earl Gohl said, “It’s a beautiful day in Appalachia because this building and school are going to help support and move forward the culture of health in Appalachia.”

The news release noted that Kentucky is one of only three states in the nation in which optometrists have the ability to perform laser and minor surgical procedures. That is a broad scope of practice authorized by those states' legislatures after lobbying from optometrists.

William T. Reynolds, secretary-treasurer of the American Optometric Association, said the college is developing a national model for access to vision care in rural communities.

“They will be the drivers of optometric education for years to come,” he said. “This school will be showing the entire nation how to properly educate and train students in this new frontier of our profession.”

The college emphasizes rural optometry and projects that more than 30 percent of its graduates will practice in medically under-served areas of Appalachia. It operates rural clinics that will serve an estimated 18,000 unique patients annually, the university said.

Monthly awards will honor people, groups for advocating policies that have made their communities or Kentucky healthier

Do you know someone who has been a tireless advocate for policies that make a community or Kentucky healthier? Their efforts can be honored by a new award for individuals and organizations who are working for policies or laws that improve health.

The Foundation for a Healthy Kentucky will present up to two “Healthy Kentucky Policy Champion” awards a month, and the winners will be eligible for the Healthy Kentucky Policy Champion of the Year award. It will come with a $5,000 grant to a Kentucky-based nonprofit of the winner's choice.

"This award is about recognizing the hard work and persistence it takes to enact health-related policies and laws," Foundation Chair Charlie Ross, a retired public-health director in the Jackson Purchase, said in a news release. "Kentucky has a lot of health issues, but we can make clear progress across entire communities and population groups with evidence-based policy changes, such as smoke-free laws that reduce exposure to secondhand smoke, complete-streets policies that allow roadways to be used by walkers and cyclers, and school programs that boost nutrition and physical activity."

Foundation President and CEO Ben Chandler said, "Business policies, local ordinances and state laws can make widespread and long-lasting improvements in the health of our people. The right health-policy changes help residents get preventive screenings and essential medical care, including mental-health services. They ensure access to healthy foods, clean air, exercise opportunities and health education. They make healthier options better understood, available to people at all income levels, and easier to choose. In short, they lead to reduced illness, better quality of life and a more productive workforce."

Nominees for the Healthy Kentucky Policy Champion award should have advanced a corporate policy, a local ordinance or a state law that will improve community or statewide health. The policy should focus on one or more specific health issues – such as a health behavior or disease, access to health care, health equity or public health, or adding a health perspective to policy. The nominees must represent a nonprofit, for-profit, educational or government entity that resides or does work in Kentucky. Political causes, organizations working for religious purposes, and groups that discriminate, are not eligible.

Nominations must be accompanied by at least one letter of endorsement (two for self-nominations) and can be made via the foundation's website. Winners will be chosen by foundation staffers and selected members of the foundation's Community Advisory Committee. Complete award qualifications and nomination requirements are at https://www.healthy-ky.org/res/uploads/media/Healthy-Kentucky-Policy-Champion-Award-Program-PUBLIC.pdf.

Trump's top health official makes Kentucky his first stop after declaring opioid epidemic a public-health emergency

Acting Health and Human Services Secretary Eric Hargan, center,
speaks with UK HealthCare Vice President Mark Birdwhistell
and project manager Beth Snider Friday at the Polk-Dalton Clinic
in North Lexington. (Associated Press photo by Adam Beam)

Kentucky Health News

The day after declaring the opioid epidemic a national public-health emergency without allocating more money for it, President Trump's top health official came to Kentucky and heard pleas for funds to meet the challenge.

In a visit that wasn't publicized in advance, acting Health and Human Services Secretary Eric D. Hargan visited a Lexington clinic Friday afternoon to meet with doctors, advocates and recovering addicts. They urged the Trump administration "to spend more money on fighting the drug epidemic," The Associated Press reports.

Hargan came to the University of Kentucky's Polk-Dalton Clinic in North Lexington, which treats pregnant women and babies addicted to opioids and other prescription painkillers. "Kentucky has one of the highest rates of babies born addicted to opioids," with 110 cases per month in 2015, AP notes.

After a private meeting with patients and advocates, Hargan toured the clinic and spoke with reporters from AP and Lexington's WKYT-TV.

“A lot of what I heard in the room is we need resources, we need money,” Alex Elswick, founder of a nonprofit that connects people to recovery resources who participated in the meeting, told AP.

"Hargan also heard from health care providers worried about the potential loss of services that came to Kentucky with the expansion of Medicaid under the Affordable Care Act," AP reports. "Agatha Critchfield, an obstetrician-gynecologist who oversees a drug treatment program for pregnant women . . . said one of the biggest things to help Kentucky was the expansion of the Medicaid program under former President Barack Obama’s health care law, which the Trump administration is trying to eliminate. She said the vast majority of patients the program treats are on Medicaid."

“Whatever your feelings are about it, substance-abuse services got better,” Critchfield said. “And so, certainly, I have concerns about that going away.”

AP notes, "It’s unclear how or when Trump’s declaration will let doctors prescribe medication, like buprenorphine, remotely without a face-to-face visit. The medicine helps people addicted to opioids with the painful withdrawal symptoms that come with quitting the drug, but doctors have been banned from prescribing it unless they meet with a patient in person. Asked if the declaration will lift those restrictions, Hargan said the Drug Enforcement Administration would have to weigh in along with state health officials."

Sperling's Best Places map, adapted

Hargan is a native of Mounds, Ill., a small town west of Paducah. He said he came to Kentucky first because it is one of the states most affected by opioids. Last year, the state had more than 1,400 drug-overdose deaths, a 39 percent increase from three years ago.

“So you look at a place that’s been very infected and also a place where they are on the forefront of developing a lot of innovative collaborative solutions,” Hargan told WKYT. “So you can put those two things together, and you can find messages, treatment and ways of dealing with it I think that can be applied nationally.”

While news reports generally said Trump made the emergency declaration, his order merely requsted the action by Hargan, who under federal law has the authority.

“When the president tells us to focus on the problem, we focus on the problem,” Hargan said. "Some of the things that I heard was that the need for resources. We heard loud and clear.”

Enrollment for Obamacare plans opens Wednesday, Nov. 1 and runs through Dec. 15; state exchange offers assistance

Open enrollment for health insurance plans at healthcare.gov begins Wednesday, Nov. 1, and continues through Dec. 15, half as long as the last annual signup period.

The state Health Benefit Exchange, formerly branded as Kynect, "is working to ensure Kentuckians are prepared, informed and have the resources they need to choose a 2018 health plan," the Cabinet for Health and Family Services said in a press release.

Kentuckians who already have a plan purchased through the exchange are automatically re-enrolled the same plan for 2018 or moved to an option "that most closely matches their current coverage," the release said. About 80,000 Kentuckians have exchange policies.

Current policyholders, and those who want to view options for 2018 on the exchange, can use the shopping tool at healthcare.gov. New users, will have to create a user account and complete an online application.

"About 80 percent of Kentuckians enrolled in the exchange qualify for tax credits or subsidies that reduce their monthly health insurance premiums," the release says. "For most of those who quality, the credits will off-set premium increases so the cost of insurance in 2018 will be about the same."

The state no longer gets federal funds for enrollment outreach and assistance, but the cabinet says it is "using a multifaceted campaign to reach current policyholders and potential new enrollees. These targeted efforts include direct mail, text messages, phone calls and emails."

The state says it is coordinating with community assisters in every county, and sending staff to more than 400 community outreach events across the state. To find an event or asisster, go to healthbenefitexchange.ky.gov. The site also includes net payment examples for all regions of the state and 2018 sample scenarios for individuals and families.

The state call center at 855-459-6328 assists Kentuckians with questions about coverage. The center can help pre-screen for eligibility and help with questions and information about the Patient Protection and Affordable Care Act, better known as Obamacare. The HealthCare.gov customer service center is also available. It can be reached by calling 800-318-2596. It is open 24 hours a day, seven days a week.

End of cost-sharing payments to insurance firms will lead to better deals for some Obamacare policyholders, if they look for them

President Trump’s Oct. 12 decision to cancel Obamacare subsidies could have an unexpected benefit for some consumers, if they shop for it.

Trump stopped reimbursing insurance companies for cost-sharing discounts Obamacare gives to lower- and moderate-income policyholders, but "State regulators and insurers anticipated that Trump would cut off the subsidy payments," Peter Sullivan reports for The Hill, a Washington, D.C. publication.

So, they raised premiums on the most common type of Obamacare policy: the "silver" plan, which is used to calculate consumer subsidies.

"If the plans are more expensive, people get a bigger subsidy. So the higher premiums lead to bigger subsidies, which consumers can now use to buy another type of plan, even a more generous 'gold' plan," more cheaply than before, Sullivan explains. "The result is that the majority of Obamacare enrollees are either held harmless or actually able to buy coverage at a lower cost than if Trump had not cut off the payments."  

However, policies from last year are automatically renewed, so policyholders will need to shop for a better deal on healthcare.gov when open enrollment begins Wednesday, Nov. 1.

"Many consumers are confused, given the debate over repeal of the law and the surrounding frenzy, and might be hit with a premium increase because they did not realize they could find a better deal on a different plan," Sullivan writes. "The Trump administration has cut back on outreach funding, which experts say could depress enrollment and lead to fewer ways for consumers to get their questions answered."

Topher Spiro, vice president for health policy at the left-leaning Center for American Progress, told Sullivan, “Even despite best efforts to educate consumers, it's going to be really hard to get out the word that there are better deals out there. In practice, in reality, there are going to be a lot of consumers who see increased costs because of this.”

Baptist Health names new CEO; will assume duties Dec. 4

Ger Colman

Gerard “Ger” Colman will be the new CEO of Baptist Health, Kentucky's largest operator of hospitals.

Colman, 47, will start work Dec. 4. A company press release said he was chosen after "an extensive national search" to replace Steve Hanson, who left in March, after the company lost money for five straight calendar quarters and laid off 288 employees, mostly at its Louisville headquarters.

Baptist has more than 25,000 employees and operates seven hospitals in Kentucky and one in Southern Indiana, as well as the Baptist Health Medical Group and more than than 300 points of care, the release said.

Colman comes to Louisville from Milwaukee, where he was chief operating officer of Aurora Health Care System. He worked for a decade at the MD Anderson Cancer Center in Houston, after working for hospitals in New Jersey.

Ky. Rural Health Association meets in Bowling Green Nov. 16-17

The 19th annual conference of the Kentucky Rural Health Association will be held in Bowling Green Nov. 16-17 at Western Kentucky University's Knicely Center, 2355 Nashville Road. Through Wednesday, Nov. 1, the registration fee is $125 for KRHA and $175 for non-members. After Nov. 1, the fees are $175 and $225, respectively. Student rates are $45 and $55, respectively. For detailed registration information, click here. For a copy the agenda and other information, go here.

Appalachia has high rates of hereditary pancreatitis; relatively new surgery to treat it is available to children 4 and older

People from Appalachia have some of the highest rates of hereditary pancreatitis in the nation, which often means living a life of uncontrollable pain, but a relatively new treatment may offer some hope.

The pancreas produces enzymes that help break down and digest food, and also insulin that controls blood sugar levels. Inflammation of the pancreas is called pancreatitis.

Pancreatitis can be caused by outside factors, like gallstones or alcohol abuse, but it can also be hereditary, which is common in Appalachia.

"In my first year working at Kentucky Children's Hospital, I saw more cases of hereditary pancreatitis than in 14 years at my previous institution," Dr. George Fuchs, a pediatric gastroenterologist, wrote in an article for UK HealthCare, republished in the Lexington Herald-Leader.

Dr. George Fuchs and Mackenzee Walters, an 11-year-old
with hereditary pancreatitis who underwent an innovative
surgery. (UK HealthCare photo)

One of Fuchs's patients with hereditary pancreatitis is 11-year-old Mackenzee Walters from Kenova, W.Va.

In January, Mackenzee underwent a new surgical procedure at Cincinnati Children's Hospital to treat the disease and it has already changed her life, making it one "free of sharp, unrelenting pain," Fuchs reports. Cincinnati Children's is one of the few children's hospitals in the nation to offer this innovative procedure.

The surgery, known as a total pancreatectomy with islet autotransplantation (TPIAT), "involves removing the entire pancreas, saving the islet cells, which produce insulin, and then re-planting those cells in the liver, where they take up residence and ideally resume their essential function," Fuchs wrote.

"The surgery is a new offering for pediatric patients ages 4 and older expecting a life of pain stemming from the disease," UK HealthCare says in a separate article about Mackenzee and the procedure. It described Mackenzee's life before the surgery as one of pain and hospitalizations that required her to miss many school days. She has had to follow a strict diet since she was 3, consisting mostly of liquids.

The story explains that most of MacKenzee's relatives, including her mother, died early in life from complications related to the hereditary pancreatitis. Kim Walters, Mackenzie's current mother and biological aunt, is the oldest surviving family member with the disease.

"Hereditary pancreatitis is pretty much all we've ever known in my family," Walters said. "It's very excruciating every day. I had my children naturally without an epidural; I would rather have a child every day for the rest of my life than live with this disease."

In December 2015, after seeing many doctors around the country, Walters consulted with Fuchs at Kentucky's Children's Hospital because Mackenzee "was suffering from unmanageable pain and taking a potentially dangerous level of medications without much relief," UK HealthCare reports. Fuchs recommended her for the 12-hour TPIAT surgery and after much consideration, Walters and Mackenzee agreed to it.

“I came to the conclusion, if nothing else if she would just be pain-free,” Walters said. “If God chose to take her six months later, at least she would have six months of no pain. And that was our goal: to make her not have pain and be able to play and do what normal kids do.”

Since the surgery, Mackenzee's islets are producing insulin, and every day the amount of supplemental insulin she needs has dropped. Now she no longer requires pain medication, UK HealthCare reports.

“I would predict she has a very high likelihood of becoming insulin-independent,” Fuchs said. “She will no longer live in the hospital, which is what these children do before the procedure because they are in so much pain. I anticipate she will get on with her life, including getting into mischief as most kids do when they become teenagers. Hopefully go on to have a productive, full life.”

Fuchs said he hopes to extend this treatment to all who qualify for it in Eastern Kentucky and surrounding areas.

Kaiser Family Foundation to hold a web briefing Oct. 31 for Kentuckians about ACA; open enrollment starts Nov. 1

At noon Oct. 31, the Kaiser Family Foundation will hold a web briefing titled "What Should Consumers Know about ACA Open Enrollment in Kentucky, Tennessee, and Virginia?" Open enrollment for 2018 plans runs from Nov. 1 to Dec. 15, a period half as long as the last one under the Obama administration.

The session "will offer a framework for understanding premiums and financial assistance in marketplaces in these three states, along with an overview of how many insurers are offering plans," Kaiser says. It will outline important new rules that could affect coverage for individuals and their families, and will provide state-specific insights on what consumers can expect and where they can go for help."

The panelists include: Karen Pollitz, senior fellow at the foundation; Jennifer Tolbert, director of state health reform and associate director of the foundation’s Program on Medicaid and the Uninsured; Kelli Cauley, assister program supervisor, Kentuckiana Regional Planning and Development Agency; Emilie Fauchet, lead Hispanic navigator for Family and Children’s Service, Nashville; and Jill Hanken, director, of the Enroll Virginia program of the Virginia Poverty Law Center.

Registration for the briefing is required and questions from the audience are encouraged.

National study finds Kentucky seniors are among biggest users of ambulances; state has a shortage of paramedics and EMTs

By Melissa Patrick
Kentucky Health News

A study aimed at providing a snapshot of how ambulance use varies between states found that Kentuckians on Medicare are among the heaviest users in the nation.

The study, conducted by the Rural and Underserved Health Research Center at the University of Kentucky, looked at Medicare beneficiaries using both ground and air ambulance services, the number of miles they were transported per year and per day, and the number of days of services they used in a year. The researchers said they used Medicare data because the benefits are the same nationwide, making it easier to make regional comparisons.

It found that Kentucky, Alabama, South Carolina, Tennessee and West Virginia were the top five states in ambulance use for all of these measures in 2012-14, with Alaska, Arizona, Colorado, Hawaii, Nevada and Utah at the bottom of the list.

Parsing data by regional census divisions, the study found found that 13 percent of Medicare beneficiaries in the East South Central division (Kentucky, Alabama, Mississippi and Tennessee) used a ground ambulance service and traveled almost 33 miles per year, on average -- the most of any division. The typical usage in the region was two days a year, with an average trip of 16 miles.

The study found that in 2014, Medicare beneficiaries in New England had the highest ground-ambulance usage and the Mountain division had the lowest. It found those in the Southeast (East South Central and South Atlantic) traveled further per year and per day, and received transportation more often than other areas of the U.S. The West North Central states (Kansas, Missouri, Iowa, Nebraska, Minnesota and the Dakotas) were transported more miles per day per beneficiary, but also traveled fewer days per year.

Air transportation was most prevalent in the West (comprising the Mountain and Pacific divisions), but the report points out that the number of people using air ambulance service was small compared to ground transportation.

The report also includes data from a 2013 Centers for Disease Control and Prevention survey that found patients 65 years and older represented almost 16 percent of emergency-room visits, but represented almost one-third of those arriving to the ER by ambulance. It also found that patients living in the South (38.3 percent) were the most likely to arrive by an ambulance, compared to the West (24.9 percent), Midwest (22 percent) and the Northeast (14.8 percent).

The researchers said they plan to do further research on the regional differences in ambulance use, noting that a quick look population, rural status, poverty and disability data didn't provide clear reasons for the regional differences.

Why does it matter?

The researchers say the study is important because it will help policy makers make better decisions about their ambulance services, which provide a vital service to communities.

"From our study, we believe policymakers and researchers need to consider differences across the regions of the U.S. when evaluating reimbursement and rules about usage," they write. "When looking at changes in the supply of ambulance services in an area, we need to consider the current rate of usage of those services. An area which relies more heavily on these services would react differently to a change in policy than an area with lesser usage."

The report notes that many ambulance services are at risk of scaling back or closing their doors because of finances. For example, they noted that Letcher County has had to reduce its ambulance service funding because of a loss of revenue from the coal severance tax.

Another challenge facing ambulance services in Kentucky is staffing. "We've got more paramedics in the state than we've ever had, but paramedics are doing more than we've ever done." Mike Poynter, the executive director of the state Board of Emergency Medical Services, told Kentucky Health News. "We're not just in the back of an ambulance anymore."

Because paramedics have so many options these days, Poynter said this has put a strain on ambulance services that are in geographic locations that are hard to staff or that can't pay a competitive salary.

For example, he said paramedics are increasingly being hired by emergency rooms, which usually offers higher wages and better benefits; that many of them are going back to nursing school because it pays more; that the influx of air-ambulances, which requires a minimum of four paramedics on board, has taken more than 200 paramedics out the traditional workforce; and that paramedics and EMTs are following the money, often living in one county, but working in another that pays a higher wage.

Kentucky news media have been reporting on these shortages. Lexington's WKYT-TV reported that the administrator of the Owen County EMS estimated a 35 percent paramedic shortage across the state. Louisville's WDRB reported that the shortage of both paramedics and EMTs has caused agencies to compete for workers, and Hardin County, which recently filled all of its positions, increased its salaries by 20 percent for part-time employees in an effort to retain more employees. The Cincinnati Enquirer reported that Northern Kentucky will need 175 new paramedics within five years, adding that the Cincinnati State Technical and Community College is launching a new training class to help meed this need. The State Journal of Frankfort reports that the city's fire-EMS agency has opened a new paramedic training program.

Poynter said one of the profession's greatest challenges is that policymakers and the public don't really know "what we do or how we do it," noting that the training to become a paramedic lasts at least 18 months, and many paramedics have advanced degrees in emergency medical care. "We've got to do better in educating the decision makers on what we actually do and how vital our role is in the community."

Study of 140,000 Americans with an average age of 69 finds that any level of regular walking can help us live longer

Photo by Justin Horrocks, NPR.org

Regular walking can lower your risk of death, even if you don't meet the minimum recommended level of physical activity, according to an American Cancer Society study.

“Going for a walk at an average to brisk pace can provide people with a tremendous health benefit. It’s free, easy, and can be done anywhere,” Alpa Patel, lead investigator of the study, told Cancer Society reporter Stacy Simon.

The study, published in the American Journal of Preventive Medicine, analyzed data from a study of almost 140,000 people who had participated in the society's Cancer Prevention Study II Nutrition Cohort. The average age of participants in the study was 69.

The study report notes previous studies have found that walking has been associated with lowering the risk of breast cancer, colon cancer, heart disease and diabetes. It adds that physical inactivity accounts for about 11 percent of the health-care costs in the U.S.

Public-health guidelines say adults should get at least 150 minutes of moderate activity, or 75 minutes of vigorous activity, spread throughout the week. Only half of U.S. adults meet this recommendation, according to the federal Centers for Disease Control and Prevention.

And while the study found that those who met or exceeded the recommended level of physical activity through walking had a 20 percent lower mortality risk, it also found that older adults who walked less than two hours per week  had a lower death risk than those who got no exercise at all.

Patel told Nick Mulcahy of Medscape that the study evaluated walking at "an average pace," which is a speed that "may cause you to eventually feel a slight increase in your breathing and will allow you to cover roughly a mile in 20 minutes."

"Walking is simple, free and does not require any training, and thus is an ideal activity for most Americans, especially as they age," says the report.

McConnell says he's waiting to hear from Trump before deciding on bill to restore cost-sharing subsidies for Obamacare policies

Kentucky Health News

Senate Majority Leader Mitch McConnell of Kentucky said Sunday that he's waiting for a clear signal from President Trump before acting on a bipartisan bill to restore cost-sharing subsidies for individual health-insurance policies under Obamacare.

“I'm waiting to hear to hear from President Trump what kind of health-care bill he might sign,” McConnell said on "State of the Union" on CNN. “If there’s a need for some kind of interim step here to stabilize the market, we need a bill the president will actually sign. And I’m not certain yet what the president is looking for here, but I’ll be happy to bring a bill to the floor if I know President Trump would sign it.” He added, “I think he hasn’t made a final decision.”

On Oct. 12, Trump said he would end the subsidies that reduce out-of-pocket costs for lower- and moderate-income people, because Congress had failed to repeal and replace the Patient Protection and Affordable Care Act. A few days later, he said he would support a bill to extend the subsidies for two years and give states more flexibility in Obamacare. But the next day, the president said "I can never support bailing out" insurance companies, which the government reimburses for the discounts.

The subsidies go to people with incomes up to 250 percent of the poverty line, about $30,000 for an individual and $61,000 for a family of four. About half the 80,000 Kentuckians with Obamacare policies get the subsidies.

Trump's press secretary suggested that the president could support the bill if it were changed, giving as an example even more Obamacare flexibility to the states: converting the funding to block grants. "White House officials said later that Trump would only sign an interim bill that also lifts the tax penalties that Obama’s health care law imposes on people who don’t buy coverage and employers who don’t offer plans to employees," reports Jill Colvin of The Associated Press. "The White House also wants provisions making it easier for people to buy low-premium policies with less coverage."

Democrats oppose all those ideas, and Senate Minority Leader Chuck Schumer, D-N.Y., said McConnell should bring the bipartisan bill to the Senate floor because it would pass with the votes of all 48 Democratic senators and at least 12 Republicans. Sixty votes are required in the Senate to overcome filibusters, except on budget-reconciliation bills.

“We have an agreement. We want to stick by it,” Schumer said, referring to the deal between Republican Sen. Lamar Alexander of Tennessee and Democratic Sen. Patty Murray of Washington, the chair and ranking minority member of the Senate health committee.

Replying to McConnell, Schumer said Trump “holds the key” to preventing further cost increases for Obamacare policyholders. He said, “Now that Leader McConnell has made it clear he will put the Murray-Alexander bill on the floor as soon as the president supports it, the president should say that he does.”

Even if the bill was to pass the Senate, it would face stout opposition in the House, where Republicans have greater control and Speaker Paul Ryan says he opposes the measure. However, Democrats will gain leverage near the end of the year, when their votes will be needed in the Senate to pass legislation to fund the government and keep it open. McConnell has said he opposes government shutdowns.

State posts weekly report on spread of flu, by county and region

Flu season has arrived, and it's time to get your shot. But if you are curious about the spread of flu in your region, the state Department for Public Health has started an online weekly report that shows the number of influenza cases in each of Kentucky's 15 area development districts and counties that have reported cases of the flu.

The data come from reports the department compiles and sends to the federal Centers for Disease Control and Prevention. It is based on laboratory-confirmed cases defined by molecular virus testing and positive virus culture test results; rapid-positive tests are not included.

The report is at http://chfs.ky.gov/dph/epi/Influenza.htm and is updated each Friday before noon, the Cabinet for Health and Family Services said in a news release.

"This new public service is an example of the cabinet’s priority to strengthen data collection and analytics and then to make the information more easily accessible," the release says. 

The health department "relies on sites such as doctors’ offices, hospitals and health departments to help track the level of influenza activity in the state and to identify which strains of the flu are circulating in Kentucky," the release explains. "These voluntary sites collect data and report influenza-like illness cases according to age groups each week. This sampling represents only a small percentage of influenza cases for the state, but contributes to the ongoing assessment of flu activity in the commonwealth and helps determine the weekly level of flu activity."

Kentucky’s current flu level is classified as “sporadic,” with 18 confirmed cases. The news release says, "Sporadic activity indicates that small numbers of laboratory-confirmed influenza cases or a single laboratory-confirmed influenza outbreak have been reported, but there is no increase in cases of influenza-like illnesses."

Vaccination can be given any time during the flu season. The recommends flu vaccine for everyone over six months of age. People who are strongly encouraged to receive the flu vaccine because they may be at higher risk for complications or negative consequences include:

• Children age six months through 59 months;
• Women who are or will be pregnant during the influenza season;
• Persons 50 years of age or older;

• Persons with extreme obesity (body-mass index of 40 or greater);
• Persons aged six months and older with chronic health problems;
• Residents of nursing homes and other long-term care facilities;
• Household contacts (including children) and caregivers of children younger than 5, particularly contacts of such children, or of adults 50 and older;

• Household contacts and caregivers or people who live with a person at high-risk for
  complications from the flu; and

• Health care workers, including physicians, nurses, medical emergency-response workers, employees of nursing home and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.

The flu can cause fever, headache, cough, sore throat, runny nose, sneezing and body aches. Flu can be very contagious. For more information on influenza or the availability of flu vaccine, Kentuckians should contact their primary care medical provider or local health department. Influenza information is also available online at https://www.cdc.gov/flu/index.htm. Here's a partial screenshot of the weekly report:

Study finds more than 1/4 of adults with health insurance are under-insured, largely because their deductibles are so high

By Melissa Patrick
Kentucky Health News

More than one-fourth of U.S. adults with health insurance were under-insured in 2016, including 44 percent who got their coverage from the federal marketplace and almost 25 percent who got their coverage from employer plans, according to a recent study.

Using data from The Commonwealth Fund's 2016 Biennial Health Insurance Survey, a report from the fund found that of all working-age adults who had health insurance for a full year in 2016, 28 percent, or about 41 million people, were underinsured.

This was up from 23 percent in 2014 and 12 percent in 2003, the first year the survey asked questions on the topic.

People in the study were considered underinsured if they had health insurance plans with high deductibles and high out-of-pocket expenses relative to their income.

More than half of the under-insured in the survey said they had trouble paying their medical bills, and 45 percent said they went without needed care because of cost.

“People who are under-insured face problems affording health care at rates similar to those seen for people with no health insurance at all, and they are almost as likely to skip needed care and to end up in debt when they get sick," Sara Collins, lead author of the study, said in a news release.

A 2016 Kentucky Health Issues Poll found that nearly one-third of Kentucky adults, whether they had health insurance or not, struggled to pay their medical bills, and one-fifth said they often delayed or skipped needed medical care because of cost.

The Commonwealth Fund's national report says the added cost burden that comes with high-deductible plans, which have become the norm, has created a steady increase in the rates of under-insured people.

In 2016, the study found that 13 percent of adults enrolled in a private plan had a deductible of $3,000 or more, up from just 1 percent in 2003. It added that only 22 percent of private insurance plans offered plans with no deductibles in 2016, down from 40 percent in 2003.

And the deductibles are even higher in the individual marketplace. "Twenty-three percent of adults with individual and marketplace plans had plan deductibles equaling 5 percent or more of income," says the report.

For example, the least expensive 2017 "silver" plan that popped up on Healthcare.gov for a Kentucky family of four making around $75,000 a year requires a $548 monthly premium (after applying the $441 per month premium tax credit) and a $12,300 deductible. It also required a $30 co-payment for every visit to the primary-care provider, with a $14,000 out-of-pocket family maximum.

The survey also found that about half of the under-insured adults who had problems paying their medical bills or had medical debt said they had used up all their savings to pay their bills, with 40 percent of them saying they now have a lower credit rating because of their bills.

This should come as no surprise. A 2017 GOBankingRates survey found that more than half of Americans (57 percent) said they have less than $1,000 in their savings accounts and 39 percent of them had no savings at all. A separate survey found that 49 percent of all Americans live paycheck-to-paycheck.

The authors say that extending the federal cost-sharing reduction payments to more enrollees, excluding more services from plan deductibles, and increasing the required minimum value of employer plans, along with addressing rising health-care costs, are possible ways to make health insurance more affordable.

Latest effort for a big increase in Kentucky's cigarette tax faces a daunting assignment, based on experience in other states

Kentucky Health News

If the latest effort to raise Kentucky's cigarette tax by $1 a pack begins to gain momentum, it can expect a big pushback from tobacco companies, if past experience in Kentucky and other states is any indication.

"Many states — Missouri, Kentucky and Georgia among them — have not significantly increased their cigarette fees in decades, bowing to pressure from tobacco lobbyists and an ingrained antipathy among conservatives to raising taxes of any kind," William Wan reports for The Washington Post.

"As a result, America’s smokers are increasingly concentrated in states where cigarettes are cheap. A pack of cigarettes will soon cost $13 in New York City, where a tax hike of $2.50 was recently passed. But in Kentucky . . . you can buy that same pack for $4.77, on average."

Kentucky has the nation's second-highest smoking rate and still produces about $250 million worth of tobacco each year, though the number of tobacco farmers in the state has declined to about 4,000. The CEO of the Foundation for a Healthy Kentucky cited the latter figure Oct. 18 in announcing a campaign with many partners to get the state legislature to raise the state's cigarette tax of 60 cents a pack by at least $1 to discourage smoking and raise money for the state.

University of Kentucky Nursing Professor Ellen Hahn, who has led tobacco-control efforts in the state for many years, told the Post, “People around here just don't like the ‘tax’ word. Between that and the grip of the tobacco industry on our legislature, it’s hard to convince anyone, especially politicians.”

The big difference in state cigarette taxes, and thus cigarette prices, "is the result of a long-running war between tobacco companies and health advocates," Wan writes. "It is also, experts say, one of the biggest reasons low-tax states now suffer from high rates of cancer, heart disease, diabetes and a multitude of other tobacco-related diseases."

Wan adds, "The battle has increasingly focused on not just whether states should increase taxes, but also by how much. Health advocates regularly fight for $1 to $2 increases, while cigarette companies push to limit them to hikes of 25 to 50 cents. That has led, at times, to bizarre conflicts. Last year, when Missouri considered raising its cigarette tax for the first time in more than two decades, tobacco companies supported the increase, while health groups such as the American Cancer Society strongly opposed it. The reason? The proposed increase was so low — either a gradual 23-cent hike or a 60-cent increase over four years — that researchers concluded smokers would pay it and keep smoking."

In Montana, a bill to raise the cigarette tax died quickly, and was even abandoned by some of its sponsors, after the two main cigarette makers, Philip Morris and R.J. Reynolds, "swarmed the halls of the state capitol, wined and dined Republican leaders, launched a sophisticated call-in campaign, and coached witnesses for hearings," Wan reports.

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, told Wan, “It’s incredibly frustrating because, unlike so many other problems in the country, this is one case where we know the solution. Not only that. It’s a solution that’s widely popular, doesn’t cost the government anything, yet these states refuse to do it.”

Myers sees little hope for a substantial tax hike in Kentucky. “People have literally been dying from this problem for years, and that still hasn’t made a difference for those legislators,” he told Wan. “The only hope I see is the economics: when the mounting health-care costs from sick and dying smokers finally gets to a point where lawmakers have no choice but to raise the cigarette taxes.”

Cigarette makers say big tax increases are unfairly exorbitant and their industry is overtaxed, Wan reports: "They point out that from 2000 to 2014, federal and state cigarette taxes have been raised 120 times. They argue that higher taxes hit the pocketbooks of convenience store owners and smokers and amount to a regressive tax on the poor. That last argument . . . angers public-health officials, because studies show that such taxes are especially effective at reducing smoking among lower-income people. By helping them quit, advocates say, taxes help struggling families escape the economic burden that cigarette addiction puts on their monthly income.

"But the most effective argument by tobacco companies has been the libertarian one: That adults should be free to choose whether to smoke and not be prodded into quitting by a nanny state."

Judge lets seven recovery clinics in Eastern and Central Kentucky re-open, but they remain under investigation

A circuit judge has ruled that seven recovery clinics in Eastern and Central Kentucky will be allowed to remain open, Jeff Noble reports for The Times-Voice in Jackson.

The Hazard, Jackson, Paintsville and Richmond clinics were raided on Aug. 29, which Noble reports resulted in five arrests at the Jackson clinic. These clinics remain under investigation by the state attorney general's office. The other three clinics are in London, Mount Sterling and Frankfort.

In issuing the temporary injunction in Breathitt Circuit Court, Judge Frank A. Fletcher wrote, “If the court does not issue a temporary injunction, the plaintiffs (The Recovery Center, LLC and Dr. George Burnette) and their patients and their employees, will suffer irreparable harm."

Noble reports that the seven clinics employ more than 78 workers and 20 contract physicians and treat more than 2,200 patients, almost all of whom receive Medicaid. All of the clinic's Medicaid payments have been withheld since Sept. 19. The judge ordered the payments resumed Oct. 16. 

Broad anti-smoking coalition launches with a lofty goal: adding $1 to cigarette tax in next legislative session

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- More than 100 people representing at least 84 groups gathered at the state Capitol Annex Oct. 18 to launch the Coalition for a Smoke-Free Tomorrow, with its leader boldly stating they hope to add $1 to Kentucky's 60-cent-per-pack cigarette tax in the 2018 legislative session.

"We hope that we can make some progress on this cigarette tax in this session that is coming up," Ben Chandler, chair of the coalition and president and CEO of the Foundation for a Healthy Kentucky, said. Noting that the big news of the day was a plan for the state's expensive pension crisis, he said, "We have one of the answers," revenue from the tax.

Coalition supporters displayed signs. (Photos by Melissa Patrick)

The foundation recently adopted smoke-free advocacy as its leading cause and is coordinating the coalition -- to the extent of lending it a modified version of its logo, which advocates held up during the launch.

Ellen Hahn, director of the University of Kentucky's Kentucky Center for Smoke-free Policy and a long-time advocate for a statewide ban on smoking in enclosed public places, said after the meeting that the Foundation is a "bully pulpit" that will speak for all of the advocates, and the coalition represents the federal Centers for Disease Control and Prevention's best practices for tobacco control -- increased taxes to discourage smoking, smoke-free policies, and helping people who want to quit.

"It's nice to have a fresh voice," she said. "I've said for years we need a bully pulpit. We need somebody who will speak up and say we need to do this."

At 24.5 percent, Kentucky has the second highest smoking rate in the nation, barely behind West Virginia's 24.8 percent. The national average is 15.1 percent. Almost 17 percent of Kentucky's high-school students are smokers, more than double the national average of 8 percent. Nearly 9,000 Kentuckians die from cancer or another smoking-related illness each year, and the state spends about $2 billion annually on smoking-related health care.

"Welcome to the cancer capital of the nation," Chandler said, noting that cancer hasn't declined as much in Kentucky as it has nationally, and cancer rates are increasing in parts of the state. He said the high smoking rate is partly to blame.

The coalition has set three goals: the $1 increase in the cigarette tax, with parallel increases in taxes on other tobacco products; helping counties and cities enact comprehensive smoking bans; and educating the public and health-care providers about a new law that requires health insurers to provide barrier-free coverage for all federally approved tobacco-cessation medications and programs.

Ben Chandler, president/CEO, Foundation for a Healthy Ky.

"These are proven laws and policy changes that will reduce our smoking rates, that will reduce our health care costs, that will in fact improve our health," Chandler said. "What's more, these policy changes don't cost an arm and a leg. In fact, they can dramatically improve Kentucky's troubling budget situation."

Chandler said Republican Sen. Stephen Meredith, a retired CEO of Twin Lakes Regional Medical Center in Leitchfield, has told him he plans to pre-file a bill to raise the cigarette tax by $1.

The current 60-cent tax is about a third of the national average of $1.71 per pack. The coalition projects that a hike to $1.60 a pack would bring in $266 million the first year.

Republican Sen. Ralph Alvarado, a Winchester physician who has sponsored several unsuccessful smoke-free bills, including one last session to make schools and school activities smoke-free, says he thinks the timing could be ripe to pass a cigarette tax because the pension system needs more money and Gov. Matt Bevin wants to reform the state's tax system.

Sen. Ralph Alvarado, R-Winchester

"The governor has charged that everything will be on the table when it comes to this tax proposal, so consequently now is the time to start looking at proposals that by themselves maybe would not pass, but as part of a larger reform has a chance to become law," Alvarado said.

Chandler said anything less than a $1 increase wouldn't work because it could be absorbed by the tobacco companies through things like temporary price cuts or other promotional discounting. He also noted that it has to be high enough to make people want to quit. "Otherwise it's just a tax increase with no health benefits, and what we care about are the health benefits,"he said.

Skeptics of a cigarette-tax increase say its revenue would decline as more people stop smoking, but Chandler said "We don't think it'll decline a whole lot," based on other states' experience. "Of course, the more it declines, the better. Any decline that does take place in the revenue the state receives is more than made up in savings on health-care cost. Anyway you look at it, it is a win for the state budget."

David Adkisson, president and CEO of the Kentucky Chamber of Commerce, said 90 percent of the chamber's members support a statewide smoking ban and legislation that would increase the cigarette tax. He added that the the costs of smoking to employers, in extra health care costs and reduced productivity, is almost $6,000 per smoking employee each year.

Jacob Steward of Bourbon County High School won applause.

"Our smoking situation in Kentucky is not only killing us, it's bankrupting us," he said.

Jacob Steward, a sophomore at Bourbon County High School and a member of a group called Students Making a Community Change, said he thought the additional tax would "significantly help" teenagers quit smoking because they would no longer be able to afford them, but he also suggested that it's also important to figure out why they ever started smoking in the first place.

"I think that one thing that should come out of this is maybe better outreach for those students. For people to actually empathize with them and understand why they started smoking to begin with," he said to a room full of applause.

Dr. Patrick Withrow, a cardiologist and director of public outreach for Baptist Health Paducah, held up a huge model of a cigarette and called it one of the most effective drug-delivery devices.

"Raising the price of cigarettes is the single most effective thing we can do to decrease smoking in Kentucky. If we decrease smoking in Kentucky, we decrease smoking disease, we decrease smoking death, and we improve quality of life," he said.

Chandler said the coalition will work systematically to help communities across the state become smoke free, with the long-term goal of passing a statewide smoke-free law. "Ultimately the goal is to get a critical mass of communities," he said. "We have 33 percent of the population covered right now; we'd like to raise that considerably and at that point maybe the state legislature might be ready to pass a statewide law."

The state House passed a smoking ban in 2014, but the bill died in the Senate, and Bevin, who took office in 2015, says smoking bans should be a local issue.

Chandler, who ran for governor as attorney general in 2003 and was 6th District U.S. representative from 2004 through 2012, was asked how hard politically it would be to pass the $1-a-pack tax increase.

"We are not overly sanguine about it. We do live in Kentucky and I think we all understand that, but things are changing in Kentucky," he said, noting that there are only 4,500 tobacco farmers in the state, down from almost 60,000 in 1992. "You are seeing a lessening of the economic impact, a lessening of the number of people who benefit from tobacco, and I think all of those things ought to come together to make this a more propitious time to get these things done."

Alvarado said opponents of the tax acknowledge that its day will come. He noted the state's budget problems and said,"It will be an accomplishment with the largest health impact for our state, and that's why we have to keep chasing the prize as a group."

Chandler concluded, "Folks, we are not going away until we succeed. We are not going away until Kentucky's smoking rate is no longer the highest in the nation. We are going to keep at it until we win this battle because our work is a win for public health, it's a win for Kentucky's budget and it's a win for Kentucky businesses."

Trump has mixed messages on Obamacare subsidies deal; McConnell is noncommittal, and some in GOP oppose it

UPDATE, Oct. 18: White House Press Secretary Sarah Huckabee Sanders said Wednesday that President Trump is opposed to the deal as it now stands. Sen. Lamar Alexander said he expected the deal to become law by the end of the year.

"A pair of leading Republican and Democratic senators reached an agreement Tuesday to fund key federal health-care subsidies that President Trump ended last week — and the president expressed support for the plan," The Washington Post reports. But it remains to be seen whether Majority Leader Mitch McConnell, other Republican Senate leaders, and leaders of the House's Republican majority, would go along.

“We haven’t had a chance to think about the way forward yet,” McConnell said at his weekly news conference, "minutes after the deal was announced about 20 feet away outside a Republican policy luncheon," Sean Sullivan and Juliet Eilperin report for the Post.

Just last week, Trump cut off the subsidies, which reimburse insurance companies for reducing out-of-pocket costs such as co-payments and deductibles for lower- and moderate-income Obamacare policyholders. Tuesday, he said of the deal, “It’ll get us over this intermediate hump,” and called it “a short-term solution so that we don’t have this very dangerous little period.”

Insurers have said that without the subsidies, "premiums for many customers purchasing plans under the Affordable Care Act would shoot up, and with profits squeezed, some of the companies would probably leave the market," The New York Times reports. That could leave some counties, especially in rural areas, without any Obamacare insurers.

The deal between Sens. Lamar Alexander of Tennessee and Patty Murray of Washington, the Republican chairman and ranking Democrat of the Senate health committee, would give states more flexibility in Obamacare. For example, Alexander "said the proposal would offer states greater freedom by allowing them to make changes to insurance offerings as long as the plans had 'comparable affordability,' which is a slightly looser definition than the existing one."

"For Democrats, not only would the cost-sharing reductions be brought back, but millions of dollars would be restored for advertising and outreach activities that publicize insurance options available in the health law’s open enrollment period, which starts next month," the Times reports. "The Trump administration had slashed that funding."

“We will spend about twice as much or more than President Trump wanted to expend,” Alexander said. “This agreement avoids chaos, and I don’t know a Democrat or a Republican who benefits from chaos.”

But the path forward remained unclear. The House is in recess week, and a spokesman for Speaker Paul Ryan declined to comment, but some leading House conservatives objected to the plan, and Rep. Tom Cole (R-Okla.), a close ally of House GOP leaders, told the Post, “None of our guys voted for Obamacare. They’re not very interested in sustaining it.” UPDATE, Oct. 18: House Speaker Paul Ryan, "reflecting his most conservative members, came out against the deal on Wednesday," the Times reports.

Across the Capitol, "Many Republican senators are distancing themselves" from it, the Post reports. However, Thomas Kaplan and Robert Pear of the Times report: "Sen. John Thune of South Dakota, a member of the Senate Republican leadership, said there would be 'a sense of urgency to move a bill,' since Mr. Trump intended to stop the payments right away."

Neonatal Abstinence Syndrome conference to be held Nov. 10 at Northern Kentucky University; it's free, but registration is required

Northern Kentucky University is hosting a conference Nov. 10 that will convene researchers from across the Ohio River together to discuss neonatal abstinence syndrome: addicted babies.

The conference, which organizers hope will be an annual event, will be held from 9 a.m. to 4:45 p.m. in Room 107 of the NKU Student Union in Highland Heights.

The conference will focus on evidence-based research into neonatal abstinence syndrome, with the hope of increasing collaboration among NAS researchers.

Vice News chart

As part of a series of stories on opioid addiction called A Nation in Recovery, Keegan Hamilton of Vice News writes that NAS "has overwhelmed the medical system, and many intensive care units for newborns are at capacity." The rate of babies being born with NAS has increased 400 percent since 2000, with one baby born with the syndrome every 25 minutes. In Kentucky, one out of every 50 newborns has NAS.

The keynote speaker for the conference will be Judith Feinberg, a professor of behavioral medicine and psychiatry at West Virginia University, who will present "The Opioid Epidemic: A view from the Belly of the Beast."

Other topics include the state of research on NAS, and what is left to find out; what communities can do about the opioid epidemic; and opioids through the eyes of a physician.

Sam Quinones, author of Dreamland: The True Tale of America's Opiate Epidemic, will wrap up the day in a conversation led by NKU Provost Sue Ott Rowlands. In a visit to the campus last year, Quinones challenged the region to develop collaborative efforts to battle the opioid epidemic.

"As part of the response to that challenge, NKU has been leading the effort in working with universities to establish ORVARC,” Rowlands said in a press release.

Quinones was the keynote speaker at the most recent Foundation for a Healthy Kentucky policy forum, where he talked about the importance of re-building communities as part of the ultimate solution to the opioid epidemic.

"Heroin is the perfect symbol for how isolated we have become as Americans, and how much we have killed off or ignored what would bring us together," he said. "I believe therefore more strongly than ever that the antidote to heroin is not Naloxone, it is community."

Registration for the conference is free, but required. Click here to register. Click here for the conference schedule.