U of L looking for a partner to help it rescue Jewish Hospital

Jewish Hospital is near University of Louisville Hospital.

The University of Louisville is looking for a partner with which to buy Jewish Hospital, Boris Ladwig reports for Insider Louisville.

"In an email obtained by Insider, University Hospital CEO and University Medical Center Board Chair Ken Marshall wrote that the institution had submitted a non-binding letter of intent to Catholic Health Initiatives, the Denver-based parent of KentuckyOne Health, to acquire its Louisville-based assets," Ladwig reports. “This will allow us to do detailed due diligence and vet potential partners,” Marshall wrote.

KentuckyOne has been trying for more than a year to sell its Louisville assets, including Sts. Mary and Elizabeth Hospital, to BlueMountain Capital Management. The deadline for a deal has been extended more than once, and "sources have told Insider that the deal is in trouble and some of the parties involved were preparing for the hospital’s closure," Ladwig reports. The email left unclear whether "the negotiations between KentuckyOne and BlueMountain are no longer exclusive."

BlueMountain told Insider in an email, “Negotiations continue to advance and BlueMountain is working collaboratively with stakeholders to reach a successful transaction.” KentuckyOne said it was continuing “confidential negotiations” with BlueMountain and the university.

"Local health care experts have said that the closing of the hospital would have far-reaching consequences for many parts of the Louisville community because the 462-bed downtown facility employs thousands of highly skilled and highly paid health care professionals," Ladwig notes. "It also takes care of tens of thousands of patients, many of them on Medicare and Medicaid."

Jewish and Sts. Mary & Elizabeth Hospital have been losing money since mid-2017, when KentuckyOne stopped managing U of L's nearby hospital, which is profitable. "Jewish Hospital and other KentuckyOne facilities are vital to the university and its medical school as they provide a home for programs including cardiology, cardiovascular and thoracic surgery, motility/gastroenterology, neurosurgery, physical medicine and rehabilitation and solid organ transplants," Ladwig reports.

U of L President Neeli Bendapudi said in November that she had begun “transitioning service lines to University of Louisville Hospital and elsewhere” because of uncertainty about Jewish. "University officials later said the institution was merely making contingency plans because of the pending end of the academic affiliation agreement between the university and KentuckyOne," Ladwig notes. "That agreement was to end Dec. 31, but has been extended until June 30."

As part of that deal, KentuckyOne "agreed to give UofL at least $35.6 million through Dec. 31 to pay for, among other items, 51 full-time resident positions at Jewish Hospital," Ladwig reports. "The terms of the agreement through June 30 are unknown, as the university and KentuckyOne have declined to provide copies. Insider has filed an open records request, but the university has not responded."

If U of L took part in a deal to save Jewish, it could need support from Gov. Matt Bevin and the General Assembly. In November, Benapudi went to Frankfort "to seek help from state officials with challenges related to the struggling Jewish Hospital but was rebuffed, sources have told Insider. It was unclear whether she sought help with an acquisition of KentuckyOne’s assets," Ladwig reports.

Poll shows plurality in Kentucky still favors Obamacare; Chandler says numbers suggest opinion of law has settled in state

Kentuckians remain divided about the Patient Protection and Affordable Care Act, but for the second straight year more of them clearly favor it than oppose it, according to the latest Kentucky Health Issues Poll co-sponsored by the Foundation for a Healthy Kentucky.

Taken Aug. 26 through Oct. 21, the poll found that 44 percent of Kentucky adults have a "generally favorable" opinion of the 2010 law, while 33 percent are "generally unfavorable" and the rest said they didn't know.

“I feel like this suggests that the number has settled into a place where it will not move,” Ben Chandler, president and CEO of the foundation and a former congressman and state attorney general, told the Louisville Courier Journal.

The numbers were the same as the poll taken in fall 2017, less than a year after its unofficial namesake and chief proponent, Barack Obama, ended his term as president. Since 2014, when "Obamacare" was fully implemented, Kentuckians' opinion of it had been marginally unfavorable.

Only 56 percent of those polled said they knew enough about the law to understand how it would affect them personally, and 53 percent said it has had no effect on them or their families; 21 percent reported negative impacts and 18 percent reported positive impacts. The poll's margin of error is plus or minus 2.5 percentage points for each number.

The law remains politically controversial, and that was reflected in its reported impact in the poll. Among Democrats, 31 percent said it had positively affected them and their families, while only 11 percent of Republicans said that while 29 percent of them said it has had a negative affect. Only 9 percent of Democrats reported a negative affect.

Ben Chandler

Chandler told CJ political writer Phillip Bailey that Kentuckians have been affected mainly by the expansion of the Medicaid program to almost 500,000 people and changes in the market for individual health insurance, which affected fewer than 300,000. About 90,000 Kentuckians have health insurance policies that are subsidized by the law; the state has almost 4.5 million people.

Chandler, a Democrat, voted against the law as Sixth Congressional District representative. He told Bailey that it has suffered from "misinformation" for years, he doesn’t regret his vote. "I never thought it was a political winner, personally," he said. "I think health care is too difficult to explain, and it's too easy to frighten people with."

Bailey writes, "Chandler, who was booted out of office in 2012, said the law hasn't covered as many people as he would have liked and hasn't cut costs to the extent he would have liked either. He described the health care law as 'essentially the Republican free-market approach to coverage' that didn't do enough. The former congressman said that the law has also been too steep of a price for Democrats at the ballot box."

Chandler said, "When it passed in 2010, the cost was so dramatic it has essentially cost, in my opinion, Democrats control of governments both on the state and national level ever since. How many other laws could have been passed that would have been beneficial from a Democratic point of view that weren't able to be done because of the controversy surrounding the Affordable Care Act?"

The poll asked these questions about the law:

“As you may know, a health-reform bill called the Affordable Care Act was signed into law in 2010.  Do you feel you have enough information about the health-reform law to understand how it will impact you personally, or not?”

“Overall, which of the following statements would you say best describes the impact of the health reform law on you and your family personally: The health-reform law has positively affected me and my family; the health-reform law has negatively affected me and my family; or the health-reform law has not had an impact on me and my family.”

For more details, click here.

Breckinridge County rejects tax for struggling hospital, which blames Medicare and Medicaid reimbursement cuts for its plight

The Breckinridge County Fiscal Court has unanimously rejected Breckinridge Memorial Hospital's request for a tax to shore up the financially struggling 25-bed hospital in Hardinsburg.

The magistrates and County Judge-Executive Maurice Lucas voted 7-0 at a special meeting on Dec. 20 to deny the request of the hospital, which operates as Breckinridge Health, a nonprofit with a home-health service, a nursing facility and primary-care clinics.

The vote followed several public hearings on the request for a tax of 10 cents per $100 worth of property, an especially controversial idea in one of the few Kentucky counties primarily dependent on agriculture.

The critical-access hospital has blamed its financial problems on reduced Medicare and Medicaid reimbursements, which account for 70 percent of its revenue. It was the lead plaintiff in an unsuccessful lawsuit challenging a decision by the Obama administration that reduced the payments to hospitals who serve a disproportionate number of low-income patients. The U.S. Supreme Court refused on Oct. 1 to hear an appeal of lower court rulings.

Ky. drops three spots, to 45th, in America's Health Rankings; big drops in vaccinations follow state rule allowing easier exemption

By Melissa Patrick and Al Cross, Kentucky Health News

Kentucky dropped three spots in the latest America's Health Rankings, to 45th from 42nd last year. It marked the third straight year that the state showed a significant increase in the number of years of potential life lost, a broad measure of overall health and life expectancy. The United States as a whole also had increases the last three years, but not as significant as Kentucky's.

Many figures in the report are based on the Behavioral Risk Factor Surveillance System, a federal poll.

The state was 42nd in health determinants, which is the measure of health-related behaviors, such as smoking; community and environmental influences; clinical care, and public policy; and 45th in outcomes, such as the rate of death from cancer, which continues to be the nation's worst.

One measure that showed a significantly worse outcome was low-birthweight babies; Kentucky dropped from 38th to 42nd among the states. Several measures of determinants showed significant declines, including: adults engaging in physical activity other than their regular work in the previous month (from 46th to 50th), children living in poverty (from 38th to 43rd), and the number of adolescents who were immunized for the human papillomavirus, meningitis and tetanus, or diphtheria and pertussis, dropping from 28th in last year's report to 40th. The report also showed a drop in immunization rates among children aged 19 to 35 months, from 16th to 23rd.

These drops in immunizations are likely a result of Gov. Matt Bevin's administration making it easier for parents to invoke a religious exemption to the law requiring vaccination to attend school. The new rules allows parents to download a form, have it notarized and submit it to their school upon enrollment, instead of having to obtain it from their health care provider along with their signature. Spectrum News reported that the number of Kentucky parents claiming religious exemption for their school-aged children increased 59 percent between the 2016-17 school year and the 2017-18 school year, when the new rule was enacted.

In addition to cancer death rates, Kentucky ranks near the very bottom among the states in several measures, including frequent mental distress (48th), frequent physical distress (49th), premature deaths (47th), preventable hospitalizations (50th), smoking (49th), physical activity (50th), and drug deaths (47th).

The state's best rankings were found in its number of high school graduates (7th), low number of violent crimes (5th), and the percentage of residents covered by health insurance (8th). Kentucky is among the states that expanded Medicaid under the Patient Protection and Affordable Care Act.

Since the rankings were first released in 1990, with the exception of 2008 when it ranked 39th, Kentucky has ranked in the bottom 10 states for health.

Here are this year's figures:

Altria, No. 1 U.S. cigarette maker, buying 35% of top e-cig maker; got Ky. legislature to drop proposed tax on e-cigs this spring

Photo by Eva Hambach, Agence France-Presse, via Getty Images

"Altria Group Inc. is nearing a deal to take a 35 percent stake in e-cigarette startup Juul Labs Inc. at a roughly $38 billion valuation, according to people familiar with the matter," The Wall Street Journal reports. "It would more than double what Juul was valued at just a few months ago, a sign of how quickly the startup has been growing and Altria’s desire to find growth outside its shrinking cigarette business. . . . The investment would give the Marlboro maker greater access to a rapidly growing but increasingly controversial segment of the nicotine market."

Juul has about 75 percent of the electronic cigarette market. Its devices can hold as much nicotine as a pack of cigarettes and have become highly popular with young people, prompting warnings that Juul is developing a new generation of smokers, not just of e-cigs but tobacco. "One out of every five high-school students—more than three million teens—reported using e-cigarettes recently, according to a federal survey conducted this past spring," the Journal notes. In Kentucky, at least as many high schoolers use e-cigs as tobacco cigarettes.

"Juul says its products are designed to help adult cigarette smokers switch to a less-harmful way to inhale nicotine," the Journal reports. "But the company’s own research shows its sleek device has hooked many people who had never smoked or had quit smoking."

The surgeon general has called youth e-cig use an epidemic, and the Food and Drug Administration "recently imposed restrictions on the sale of certain flavors of e-cigarettes that it says appeal to teens," the Journal notes. "Juul refills with non-tobacco flavors such as mango and cucumber account for a sizable chunk of its sales, according to analysts. Juul has taken steps to restrict sales to minors, including pulling all but its mint, menthol and tobacco-flavored products from bricks-and-mortar stores. It continues to sell all its flavors on its website, which it says has age verification technology. The company has discontinued its use of U.S. social media."

The company's stake in Juul "would also expand Altria’s reach beyond the U.S,," the Journal notes. "Philip Morris International Inc. sells Marlboro and other Altria brands outside the U.S. Juul products are sold in Canada, the U.K., Israel and Russia, and the company has expansion plans in Europe and Asia." Philip Morris USA, another Altria subsidiary, is the No. 1 U.S. cigarette maker.

After a visit from Altria's chief lobbyist this spring, leaders of the state Senate removed a proposed 15 percent tax on electronic cigarettes from the bill that raised the state cigarette tax 50 cents a pack, to $1.10. The company's apparent objectives were to limit the tax to that amount and keep it from applying to e-cigs and smokeless tobacco. It has a smokeless plant in Hopkinsville.

After the session, Altria reported spending $379,760 to lobby it. That was more than double the sum spent by any other business, and about three times more than the average the company spent in each of the previous four legislative sessions, according to the Kentucky Legislative Ethics Commission.

Most on Medicaid will have co-payments starting Jan. 1; foes say it's a barrier to care, proponents say it improves engagement

By Melissa Patrick
Kentucky Health News

Starting Jan. 1, most adult Medicaid beneficiaries in Kentucky will be required to make co-payments for many of their health-care services, a rule change that prompted 26 organizations to sign a letter asking state officials to reconsider this decision because they say it will create a barrier to care.

"Requiring co-payments from Medicaid beneficiaries is a choice each state must make. Any budgetary benefits are limited at best, as the unintended consequences of creating barriers to care are often offset by increased costs down the road," says the Dec. 11 letter to the state's new Medicaid commissioner, Carol Steckel.

Co-payments have long been required from Medicaid members who are aged, blind or disabled. They are not part of the "managed care" system in which insurance-company subsidiaries or other organizations oversee care funded by Medicaid. The managed-care organizations, or MCOs, have been able to waive co-pays, "and all of them have waived some or all of those," said Doug Hogan, spokesman for the state Cabinet for Health and Family Services. "The new regulation will remove that ability to waive the co-pays and create more uniform application across all populations."

These new co-pay rules are separate from the state's new Medicaid plan, which is set to roll out on April 1. And as soon as that plan is implemented, monthly premiums ranging from $1 to $15 per month will replace the co-pays for most beneficiaries. Implementation could be delayed by courts.

The rule that takes effect Jan. 1 requires MCOs to charge co-pays that range from $1 for some prescriptions to $50 for any type of inpatient service, including mental-health and substance-abuse admissions.

The rule exempts children, pregnant women, hospice patients and beneficiaries who have reached their "cost sharing limit" for the quarter, which amounts to 5 percent of a person's household income during three-month quarters of the year.

The  rule also exempts a few services, including emergency care, some family planning and preventive care, such as screenings, check-ups and patient counseling to prevent illnesses, like diabetes or heart disease.

Providers cannot refuse to see Medicaid beneficiaries who are below the federal poverty level if they cannot afford their co-payment, but can refuse services to those above the level -- though this has to be their current business practice for all patients, not just those on Medicaid.

The cabinet has provided a PowerPoint presentation to help providers navigate the changes.

The 26 organizations that signed the letter included links to two bodies of research that support their concerns that even small co-pays will cause many to go without care. One, published by the National Institutes of Health, cites several examples of state co-pay requirements that reduced faithfulness to prescriptions, and another that reviewed 65 studies from the Kaiser Family Foundation, which found that even modest co-payments create barriers to care for low-income populations.

"Having worked hand-in-hand with state agencies, providers, application assisters, legal aid programs, and others across the commonwealth to get Kentucky covered, we have found that even modest financial barriers can mean the difference between having access to healthcare or going without," says the letter.

Hogan said state health officials hope that mandatory co-payments and the new Medicaid plan will "empower individuals to improve their health and their lives," as well as help them to transition from Medicaid into commercial health insurance.

"We see from other states that premiums have an even more profound effect at increasing engagement and improving utilization," he said. "For example, in Indiana, people who chose the premium plan over the co-pay plan had nearly double the rate of primary-care utilization.  We think that may be because premiums are easier to plan and budget for, and serve as a monthly reminder that they have health coverage that they associate value with—which makes them more likely to use it in a preventable manner."

Good news: About 1/2 of Ky. adults got a flu shot in the past 12 months. Bad news: About 1/2 didn't. It's not too late to get one.

By Melissa Patrick
Kentucky Health News

A new Kentucky Health Issues Poll found that about half of Kentucky adults got a flu shot in the last 12 months. This is great news since it is higher than the prior year, when more than 300 Kentuckians, including five children, died from influenza -- but it also means the other half need to get vaccinated, since the recommendation is for everyone six months and older to get a shot each year.

Centers for Disease Control and Prevention graphic

"If you have not received your flu shot this season, please get it now," Dr. Brent Wright, president--elect of the Kentucky Medical Association, said in a news release from the Foundation for a Healthy Kentucky, which co-sponsors the poll. "Make no mistake, the flu is not a cold; it is serious and not something to mess around with. . . . Please give yourself, your family, and your community a gift by getting a flu shot this season."

Wright, who is also the foundation board's treasurer, stressed that the flu can be dangerous, often leading to a lengthy illness, hospitalization, and in some cases death. Flu season usually peaks between December and February, but can last as late as May.

Last flu season, more than 10,500 Kentuckians were infected and 333 Kentuckians, including five children, died from flu complications. For the season, only 41 percent of Kentucky adults got a flu shot and 55 percent of children did, according to the federal Centers for Disease Control and Prevention.

Kentucky continues to be under a flu threat that the CDC defines as "regional," with confirmed cases in 15 of the state's 17 health regions. So far this season, Kentucky has had 299 cases and two deaths from it, according to the state Department for Public Health weekly flu surveillance report.

The health issues poll, taken Aug. 26 to Oct. 21, found that 54 percent of Kentucky adults got a flu shot in the previous 12 months.

It also found that women were more likely (58 percent) than men (48 percent) to get a shot. People 65 and older were most likely to get vaccinated, at a rate of 69 percent, while those between the 30 and 45 were the least likely, at 42 percent.

Asked their main reason for not getting the flu vaccine, 56 percent reported one of the common misconceptions about the flu, including that they thought it would make them sick, that it was not effective, or that they didn't need it because they were healthy. All of these persistent myths have been debunked.

"In fact, flu vaccines do not cause the flu . . . and it's important for both healthy people and those who may be vulnerable to serious flu complications to get vaccinated annually, according to the CDC," says the release.

Others said they didn't get the vaccine because of access issues, including cost, lack of insurance, not knowing where to get one, and because getting one interfered with their work schedule.

If you're looking for a place to get your flu shot, the CDC offers an interactive "flu vaccine finder" that allows you to type in your ZIP code to find nearby locations that offer flu shots. Local health departments offer the vaccine.

"Annual flu shots work," Ben Chandler, president and CEO of the foundation, said in the release. "They keep us from getting the most common strains of flu each season and reduce the risk of complications and even death if we do end up getting sick. Just as important, when the majority of us get our flu shots, we provide a stronger measure of protection for infants and those with compromised immune systems who cannot get the vaccine."

The Kentucky Health Issues Poll is also funded by Interact for Health, a Cincinnati-area foundation. The latest poll surveyed a random sample of 1,569 adults via landlines and cell phones. The margin of error for each statewide result is plus or minus 2.5 percentage points.

Employer-sponsored health plans in Ky. saw modest cost hikes in 2017, but many people struggle with premiums, deductibles, etc.

By Melissa Patrick
Kentucky Health News

While much attention has recently been given to the number of people who sign up for health insurance on the federal exchange, the reality is that most people get their health insurance through their employer. A recent analysis by The Commonwealth Fund, a foundation interested in the health-care system, shows that the overall cost of employer-sponsored plans keeps going up.

“The vast majority of people under age 65 in the U.S., 152 million, get their health insurance through an employer, and many of them can barely afford to pay for it. Several bipartisan policy fixes have the potential to reduce health care burdens for workers and families struggling to afford the health care they need, while also making our health system work better for everyone," Dr. David Blumenthal, president of The Commonwealth Fund, said in a news release.

According to the analysis, 56 percent of people under 65 get their health insurance through an employer, while only 9 percent get their plans through a state or federal marketplace.

In Kentucky, the most recent open enrollment snapshot shows that 90,625 Kentuckians signed up for 2019 coverage on the federal exchange, compared to nearly 2 million who got coverage from an employer in 2017, according to the latest numbers reported by the Kaiser Family Foundation.

Average employee premium contribution, plus average deductible, as a
percentage of median state income in 2017. It shows Kentuckians spent
13 percent of their annual income on health coverage, or $7,136.

The analysis found that Kentucky families covered through employer plans spent, on average, 13 percent of their yearly income toward health coverage in 2017 — or $7,136 in potential out-of pocket spending. That was slightly above the national average of 12 percent.

That was only a 1.6 percent increase from 2016, compared to a 6.8 percent jump in the national rate. But when you compare the state's average potential out-of-pocket spending in 2017 to what Kentuckians were paying a decade ago ($3,886), it's up 84 percent.

And because Kentuckians make less money on average than people in other states, they spend a larger share of their incomes on their premiums and deductibles. For example, in Kentucky, the average household income was about $47,000 between 2016 and 2017, compared to $62,000 nationally.

“The cost of employer health-insurance premiums and deductibles continues to outpace growth in workers’ wages," Sara Collins, lead author of the study, said in a Commonwealth Fund news release. "This is concerning, because it may put both coverage and health care out of reach for people who need it most — people with low incomes and those with health problems."

The analysis also showed that premium cost for single coverage plans saw the biggest jump between 2016 and 2017, from $1,290 to $1,453, or nearly 13 percent. The rest of the nation saw a 6.8 percent increase for this measure.

But otherwise, the changes were modest.

Deductible costs for single coverage dropped 1.4 percent, to $1,878; premiums for family coverage increased .6 percent, to $4,764 and deductibles for the combined average of single and family coverage increased by .4 percent, to $3,138. National increases were much higher for each of these measures.

In general, the report says that employees pay about one-fourth of the employers portion of the premium costs — and that holds true for Kentucky. Employer-sponsored insurance premiums for single coverage in Kentucky in 2017 was $6,101 (up 6 percent from 2016) and $16,948 for family sponsored coverage (up 1.6 percent from 2016).

The researchers called on policymakers to address these rising health care costs and offered specific, detailed suggestions. "Policymakers will need to recognize that the increasing economic strain of health care costs facing middle-income and poor Americans is driven by multiple interrelated factors and will require a comprehensive solution," says the report.

The study used data from the federal Medical Expenditure Panel Survey. Researchers surveyed more than 40,000 business establishments in 2017, with an overall response rate of 65.8 percent. It looked at both premiums, the amount a person has to pay each month for their plan, and deductibles, the amount a person has to pay before an insurance company's payments kick in.

More children in state and nation lack health insurance; Kentucky kids' uninsured rate rose to 3.8% in 2017, from 3.3% in 2016

By Melissa Patrick
Kentucky Health News

For the first time in nearly a decade, the number of uninsured children in the United States and Kentucky increased, according to a report from Georgetown University in Washington, D.C.

From 2016 to 2017, the number of uninsured U.S. children rose by 276,000, to nearly 4 million. About 5 percent of the nation's children were uninsured in 2017, up from 4.7 percent in 2016.

Uninsured Kentucky children (Ky. Voices for Health chart; click on it for a larger version)

In Kentucky, 6,000 fewer children had health insurance in 2017, for a total of 41,000. That's an increase to 3.8 percent, up from 3.3 percent in 2016.

The report, based on Census Bureau data, found that no state saw its number of uninsured children decline from 2016 to 2017. The rate did drop in the District of Columbia.

In six of the previous seven years, the percentage of U.S. children with health insurance increased, first due to the Children's Health Insurance Program (K-CHIP in Kentucky), then with the 2014 implementation of the Patient Protection and Affordable Care Act.

"Having health insurance is important for children because it improves their access to needed preventive and primary care such as well-child visits, immunizations, and prescription drugs. Insured children are also less likely to miss school, and they are more likely to have better economic and educational outcomes when they grow up," Joan Alker, co-author of the study and executive director of Georgetown's Center for Children and Families, says in the news release.

The report says the declines are likely the result of influences that have created an "unwelcome mat" effect, including: efforts to repeal the ACA; an "unprecedented delay" by Congress to fund CHIP; repeal of the law that required most peoples to have health insurance or pay a fine; huge cuts in outreach and enrollment programs for ACA insurance; a shorter open enrollment period for that insurance; and changes in state Medicaid systems that may have tightened verification procedures.

In addition, the report says that several new Trump administration policies deter parents who are immigrants from enrolling their children, even if the child is a U.S. citizen. One-quarter of all children under 18 living in the U.S. have a parent who is an immigrant.

"Declines in child coverage rates occurred in 2017 despite an improving economy and low unemployment rate, strongly suggesting that federal actions contributed to a perception that publicly funded health coverage options are no longer available or, in the case of an immigrant parent, created concern about enrolling their child in public coverage for fear of reprisal," says the report.

The report adds that while the largest source of coverage for children in 2017 was through employer-sponsored insurance, the increases made in this market were not enough to compensate for the decline in publicly-funded coverage.

The report also shows that states that expanded Medicaid to people with incomes up to 138 percent of the federal poverty level, as Kentucky did, had fewer uninsured children. For example, of the 276,000 children who lost coverage in 2017, three-fourths, or 206,000, lived in non-expansion states.

Research shows that children whose parents are insured have considerably higher rates of coverage than those whose parents are not.

“We’ve made so much progress in Kentucky since 2014,” Emily Beauregard, executive director of Kentucky Voices for Health, said in a KVH blog post. “By getting parents covered under our Medicaid expansion and health insurance marketplace, we’ve seen a dramatic decrease in the number of children who were uninsured. It would be a shame to allow all that we’ve achieved for Kentucky’s children fall by the wayside.”

The report concluded with a dire warning: "Barring new and serious efforts to get back on track, there is every reason to believe the decline in coverage is likely to continue and may get worse in 2018."

Surgeon general issues national advisory on epidemic use of youth e-cig use; all agree it will take everyone to curb epidemic

By Melissa Patrick
Kentucky Health News

Electronic-cigarette use among teens is so widespread that the top U.S. public health official has issued a rare national advisory stressing the importance of protecting children from such devices, saying they are setting them up for a lifetime of nicotine addiction and associated health risks.

"We are in the midst of a historic and unprecedented increase in youth use of any substance," Surgeon General Jerome Adams said during a Dec. 18 news conference when he announced the advisory.

Federal research released in November showed a 78 percent increase in e-cigarette use among high-schoolers between 2017 and 2018, with the number of users surpassing 3 million. The same report showed use by middle schoolers increased 48 percent from the year before.

And this week, a National Institute on Drug Abuse study of 45,000 eighth, 10th and 12th graders found similar increases, with vaping among high school students near doubling from 11 percent in 2017 to 21 percent in 2018. In addition, this study found that nearly 8 percent of 12th graders used e-cigs to vape marijuana.

Elizabeth Anderson-Hoagland of Kentucky's Tobacco Prevention and Cessation Program said in a state-issued Facebook post about the surgeon general's advisory that while the latest research doesn't include state specific numbers, this uptick in e-cig use among teens is also a problem in Kentucky.

"Schools are saying that kids are using them in the classrooms, using them in the hallways, using them during games," she said. "It's just everywhere. It's really exploded"

Foundation for a Healthy Kentucky photo

E-cigarettes come in all shapes and sizes, but the most popular one is the Juul, which looks like a USB flash drive. Kids love them because they are easy to hide, are essentially odorless and come in flavors they like. Juul commands about 75 percent of the market.

Another problem is that youth don't realize e-cigs are harmful, and don't know they contain nicotine, which is highly addictive and harmful to brain development. In fact, one Juul pod can have as much nicotine as a pack of cigarettes and even products that are advertised as nicotine-free have been found to contain nicotine.

"Once they try the flavors, they get the nicotine hit -- and they don't realize that most products contain nicotine," said Anderson-Hoagland. "So they come because it taste good, and they stay because it's addictive."

Teens also have the misconception that they emit a harmless water vapor, when in fact they can contain harmful substances, including" ultrafine particles that are inhaled into the lungs, flavorings such as diacetyl, volatile organic compounds, heavy metals and cancer-causing chemicals," according to a Foundation for a Healthy Kentucky news release.

"So in those very important adolescent years when a child's brain is developing, these compounds can have very negative impacts," Dr. Jeff Howard, commissioner of the state Department of Public Health, said in the Facebook post.

The e-cigarette problem is so prevalent that the U.S. Food and Drug Administration has called it an epidemic, prompting the agency to implement and advise for stricter measures to keep the products out of teens' hands. They include, among other things, a crackdown on flavored products, which teens report is the main reason they start using the products.

The surgeon general said that while we are "late to the game" on this issue, everyone has a role to play in stopping this epidemic: parents and kids, teachers and administrators, health professionals, state and local governments and the federal government.

Juul has recently run large newspaper advertisements touting it as a device that helps smokers quit tobacco. Adams said neither he nor FDA Commissioner Scott Gottlieb "are against exploring the harm-reduction potential of these products, but we will not stand for another year of exponential, unprecedented, historic rises in youth use of these products."

At an e-cigarette conference held Dec. 10 in Louisville, Brian King, deputy director for the Office on Smoking and Health at the federal Centers for Disease Control and Prevention in Atlanta, pointed out that cessation is a necessary prerequisite for e-cigs to be considered a harm reduction product, and so far research does not support that this is the case.

"In the end, if we're going to have a benefit from e-cigarettes, the adult cessation has to outweigh youth initiation and that is simply not what we are seeing, particularly as we are seeing skyrocketing rates of use among youth. Remember, you have 2.8 percent of adults using the product and 21 percent of high school students. A seven- to eight-fold higher rate of use among kids compared to adults and that is why the public health community is so justifiably outraged over what we are seeing. We cannot leave kids behind in this discussion of harm and risk reduction among adults and we don't even have a product that has been effectively proven to help adult smokers quit," he said.

In Kentucky, about the same number of high-school students smoke cigarettes as use e-cigs, 14 percent. But health advocates warn that e-cig use is likely much higher among the state's youth because the survey was taken before the introduction of Juul and Juul-like products.

Howard echoed the surgeon general's call to action: "I'm very concerned about the use of electronic cigarettes and I encourage all parents, educators and community members to join me in making sure our teens and youth are aware of the risk of electronic cigarettes and doing as much as we can to prevent the use of electronic cigarettes in this population."

CDC image

Anderson-Hoagland was more specific in what needs to be done to stop this epidemic, calling for communities to enact tobacco-free smoke policies that include e-cigarettes, 100 percent tobacco-free school policies, and increased education about these products aimed a both adults and teens.

"We've been down this road before with regular cigarettes, so really we need to use the same playbook for e-cigarettes," she said.

King, of the CDC, added price increases, increased access to proven cessation products and mass media campaigns to this list of ways to stop this epidemic. As of now, Kentucky does not tax e-cigs, nor do they fall under the definition of tobacco in the state, though they are included in the federal definition.

"When it comes to tobacco control, prevention is key," King said. "We've got to stop those nine in 10 adults who began as youth from starting altogether. When you implement these [policies] in the context of effective regulation, you are going to get effective prevention measures that impact the population."

The American Cancer Society Cancer Action Network commended the surgeon general's advisory, but said more federal regulation is necessary to get in front of this epidemic.

“While a number of states and communities have begun to take action to address this epidemic across the country, community level action alone cannot solve this crisis. The most substantial way to begin reversing this epidemic of e-cigarette use among youth is for the [FDA] to exercise its full regulatory authority and conduct the legally required review of e-cigarettes and cigars, including prohibiting their use of flavoring, in order to be on the market," it said in a statement.

Beshear says he will 'lead the fight' against ruling on Obamacare, then demurs, saying he'll be 'as vocal if not more' than other AGs

Attorney General Andy Beshear, right, meets Gov. Matt Bevin

before one of Bevin's State of the Commonwealth addresses.

(Associated Press photo by Timothy D. Easley)

By Al Cross
Kentucky Health News
This story has been updated.

FRANKFORT, Ky. – A federal judge in Texas has ruled the Patient Protection and Affordable Care Act unconstitutional, making likely that the U.S. Supreme Court will get its third chance to strike down the 2010 law widely known as Obamacare.

The ruling sparked sharp objections from supporters of the law, including Kentucky Attorney General Andy Beshear, who said on Twitter Saturday, “I will lead the fight to overturn Friday night’s ruling from Texas that could eliminate health care coverage for more than 1.3 million Kentuckians and which would cost our state more than $50 billion” in federal health-insurance payments over 10 years.

At a news conference Monday, Beshear declined to repeat his assertion that he would "lead the fight." He is among 16 Democratic attorneys general who intervened to defend the law after the U.S. Justice Department did not.

"It's fair to say there has been more than one leader, but we have been as active as any other state and will continue to be that active," Beshear said. Later, he said he would be "as vocal if not more vocal" than the others, and that potential impacts on Kentucky, "given the health of our people, I believe is more stark than just about any other state."

"The ruling would devastate Kentucky," Beshear said. "It would devastate our families, and I will not let it stand." He listed 10 harms, including coverage for pre-existing conditions, which about half of Kentuckians have ""everything from asthma to acne"); repeal of the Medicaid expansion, which has covered almost half a million Kentuckians; increased financial threats to rural hospitals; and re-creation of the "donut hole" for prescription drugs in Medicare.

U.S. District Judge Reed O'Connor of the Northern District of Texas ruled in a lawsuit by 18 Republican attorneys general, who argued that the law is unconstitutional because the 2017 tax cut passed by Congress repealed the tax penalty for not having health insurance, and the 2012 Supreme Court ruling upholding the law said the rule was a constitutional exercise of Congress's taxing power.

Political ramifications

Beshear said the ruling goes farther than even the Republican AGs wanted, in throwing out the whole law, and "I believe that most legal scholars will tell you that we'll be able to get it overturned." A Wall Street Journal editorial said so, but said the controversy could backfire on Republicans.

Of the 16 Democratic attorneys general in the case, Beshear is the only one on the ballot in 2019, as a candidate in the May 21 primary for governor, though Mississippi Attorney General Jim Hood is planning to run for the open governorship in Mississippi, advocating expansion of the state's Medicaid program under the Affordable Care Act.

In Kentucky, Gov. Matt Bevin, a critic of the law and Beshear (the feelings are mutual), is likely to be the Republican nominee for governor. His predecessor, Democrat Steve Beshear, is the attorney general's father and an outspoken advocate of the law – which he embraced by expanding Medicaid.

Asked if the other AGs would let him take the lead because he is on the ballot, Beshear said, "At the end of the day, this isn't about any election. This is about future health-care coverage for 1.3 million Kentuckians." Medicaid covers almost 1.4 million, but the law's expansion of it covers only 450,000, and fewer than 100,000 Kentuckians are enrolled in insurance plans subsidized by the law.

Asked if most Kentuckians favor or oppose the law, Beshear said they favor the Medicaid expansion, covering people with pre-existing conditions and those who become sick, and not discriminating against women and seniors. "I believe that if Kentuckians understand what's at stake," he said, "they will most certainly be with us on this."

Asked if the case gives him and other Kentucky Democrats a stronger talking point on an issue that was helpful to Democrats in other states in last month's elections but not so much here, Beshear said, "I want to give Republicans the opportunity to be supportive of this."

As support for medical marijuana in Kentucky increases, a resolution asks the federal government to speed research on it

By Melissa Patrick and Al Cross
Kentucky Health News

As support for legalization of marijuana for medicinal purposes grows in the General Assembly, legislation has again been filed to ask the federal government to expedite research on the idea. A leading advocate of medical marijuana says the measure may be "a ploy to delay" action on his bill.

Rep. Danny Bentley and Dianne McFarling, a certified
prevention specialist, spoke at the Dec. 12 interim joint
health committee meeting. (Photo by Melissa Patrick)

The research resolution is sponsored by Republican Rep. Danny Bentley, a pharmacist from Russell in Greenup County. He told the interim joint health committee Dec. 12 that while we have always sought remedies when what was available was insufficient, sometimes those remedies caused more harm than good.

This "history of error in cures" made evidence- based medicine become the standard of care, and that standard should be applied to medical marijuana, Bentley said.

To conduct research on marijuana's medicinal properties, the federal government would have to move marijuana from a Schedule I, a list of drugs with no medicinal use, to Schedule II.

Noting that there have been federal barriers to research on the medical benefits of cannabinoids, the chemical constituents of the cannabis plant that can be used legally, he said, "These barriers established by the federal government need to be adjusted to allow a responsible and swift advancement of research and conclusion. . . . We need more research on the harmful effects. Benefits are modest at best; harms are unknown."

Bentley alluded to the growing demand for medicinal marijuana: "Who is not deeply moved by the stories of those desperate for relief, those people suffering? Who does not want to do all within their power to help those silent sufferers? It is truly our cast to help, not harm them and the many thousands of other who could be harmed by us if in the name of compassion we make a hasty, uninformed, unscientific decision that is not our decision to make."

Rep. Jason Nemes, R-Louisville, told WDRB that he plans to refile his 2018 bill to legalize and regulate medical marijuana on Jan. 10. "Nemes said more research is needed, but he has not decided whether to support Bentley’s resolution," WDRB reports. “If I see it as a ploy to delay, I’ll be strongly against it,” Nemes told Lawrence Smith of the Louisville TV station.

The legislature debated a medical-marijuana bill in 2018, but ran out of time to find compromises that might have allowed it to pass. A resolution like Bentley's passed the House but died in the Senate.

Sen. Whitney Westerfield, R-Hopkinsville, who is running again for attorney general, said at the Kentucky Chamber of Commerce's legislative preview meeting Dec. 3 that he was "not on board just yet" for medical marijuana but "I suspect it'll eventually pass. . . . I just hope we get it right."

State Justice Secretary John Tilley said Kentucky can take guidance from the 33 states that have legalized medical marijuana, "and make sure the people who need it do get it. Males 18 to 30 with low back pain don't need to utilize it."

Nemes told the meeting in Lexington that he suspects marijuana is a gateway drug, as critics say, but "What I do know is that it's an off-ramp for people threatened with addiction" to painkillers. "Medical marijuana is a no-brainer, in my mind."

Sen. Morgan McGarvey, D-Louisville, the new Senate minority floor leader, told the audience, "Even if you're for it, as I am, it's incredibly complex."

Sen. Ralph Alvarado, R-Winchester, a physician, said at the committee meeting that more research is needed and the medical community is open to it, and looking for guidance on dosing, frequency of use and what medical conditions to prescribe it for. "We want to have the proof, and if the proof is there, then we use it," he said.

Kim Moser, R-Taylor Mill, the incoming chair of the House Health and Family Services Committee, said she plans to co-sponsor Bentley's bill: "I think we need to be patient, and I understand that there are patients who are feeling, for whatever reason, very desperate for some relief and this seems to be some sort of quick answer, but we don't do that with any other medications."

Dianne McFarling, a certified prevention specialist with the state's Marijuana Prevention Enhancement Site, gave the committee some facts about marijuana, which is increasingly known by its botanical genus, cannabis.

She said Kentucky has been among the top five domestic producers of marijuana for at least five years, based on rough official estimates: "We produce enough cannabis to provide 239 joints for every man, woman and child in the state of Kentucky every year. That's a lot of marijuana being grown in a state where we have no legalization."

She also went over several youth surveys around marijuana use, noting that as the perception of risk around use goes down, as often happens when states legalize it, youth use of marijuana goes up.

Ky.'s hepatitis A outbreak is over 3,000 cases. It may be slacking off, but it's done that before. Advice: wash hands, get vaccinated.

Chart by WKYT-TV, based on data from Kentucky Department for Public Health, adapted by Kentucky Health News

Kentucky Health News

Kentucky's hepatitis A outbreak appears to have hit a plateau or even be slacking off, but it has made such moves before, and then resurged. And the state continues to record about 60 new cases a week. The state Department for Public Health has logged 3,122 cases from September 2017, the start of the outbreak, through the first week of December 2018.

That being said, the department's most recent weekly report showed the largest one-week drop in reported cases since the outbreak began, to levels that haven't been that low in five months. The biggest single week was in late October.

The outbreak has been blamed for the deaths of 19 Kentuckians, "and 82 percent of Kentucky's 120 counties have reported at least one case," Lexington's WKYT-TV reports. "More than half of the cases have led to patients being hospitalized. . . . Carter County has the highest incident rate per capita."

Hepatitis A is transmitted by oral contact with fecal matter, and there is no cure, so authorities urge hand washing and vaccinations. The disease attacks the liver and causes symptoms including abdominal pain, nausea, diarrhea, fever and yellowing of the skin.

Kentucky's spending on tobacco prevention and cessation goes up, but still falls far short of federal recommendations

Kentucky leads the nation in smoking and tobacco-related health costs, but ranks 35th in how much it spends from tobacco-tax revenue and the millions it gets from the 1998 cigarette manufacturers settlement with states that sued them to recover smoking-related health costs.

The presumption was that much of the settlement would go toward tobacco prevention, but it hasn't. Kentucky funneled half its settlement money into improvement of the agricultural economy.

States are ranked in the annual report from the Campaign for Tobacco-Free Kids, the American Heart Association, the American Cancer Society Cancer Action Network, the American Lung Association, the Robert Wood Johnson Foundation and the Americans for Nonsmokers’ Rights and Truth Initiative.

The report, "Broken Promises to Our Children: A State-by-State Look at the 1998 Tobacco Settlement 20 Years Later," says Kentucky will get an estimated $507.3 million in tobacco taxes and settlement money this, but will spend only $3.8 million on tobacco prevention. That is only 6.7 percent of the $56.4 million that the federal Centers for Disease Control and Prevention recommends the state should spend for tobacco prevention and cessation.

Campaign for Tobacco-Free Kids chart

That said, this year's spending is about 46 percent more than last year, when the state allocated $2.6 million for tobacco prevention and cessation.

"The increased amount is based on some changes in how the Master Settlement Agreement funds are distributed," Doug Hogan, spokesman for the Cabinet for Health and Family Services, said in an e-mail. "The increase for tobacco prevention and cessation did not take funding away from another area."

He said the additional settlement money will be used to develop a new campaign against smokeless tobacco use by rural youth, to provide nicotine-replacement therapy for people who are uninsured or on Medicare and enroll on the state "quitline," and to enhance and expand some other programs.

The quitline can be reached by calling 1-800-QUIT-NOW or by texting QUITKY to 797979. It can also be reached at www.quitnowkentucky.org.

Meanwhile, the tobacco industry spends $276.7 million on marketing in Kentucky, which amounts to $73 in marketing for every $1 spent on prevention.

"Kentucky simply can no longer afford this off-kilter equation," Ben Chandler, chair of the Coalition for a Smoke-Free Tomorrow, said in a news release. "Our health-care costs for smoking-related diseases total $1.92 billion every year. The Master Settlement Agreement was intended to help mitigate the cost of Big Tobacco's addiction-model business plan." Chandler participated in the settlement as state attorney general.

He added, "We're grateful for the additional funding included in the next budget, and will advocate for continued increases to prevent a new generation with tobacco addiction, and to help current smokers quit for good."

Kentucky is not alone in its low settlement funding to prevention programs. The report says only two states, California and Alaska, provide even 70 percent of the recommended CDC funding, and 28 states and the District of Columbia spend less than 20 percent of the recommended amounts.

Court of Appeals OKs release of court records that could reveal more about how company promoted OxyContin, opioid epidemic

The state Court of Appeals on Friday upheld a Pike County judge’s ruling to release secret records about the marketing of OxyContin, the branded form of oxycodone that "has been blamed for helping to seed today’s opioid addiction epidemic," reports Stat, the medicine-and-science publication of The Boston Globe, which fought to get the records.

Purdue Pharma is privately held. (AP photo by Douglas Healey)

In the court file is a deposition of Richard Sackler, a former president of Purdue Pharma, the family-controlled company that makes OxyContin and pleaded guilty in federal court to fraudulently marketing of as less addictive than other painkillers.

The deposition "is believed to be the only time a member of the Sackler family has been questioned under oath about the marketing of OxyContin and the addictive properties," Stat's David Armstrong and Andrew Joseph report. "Other records include marketing strategies and internal emails about them; documents concerning internal analyses of clinical trials; settlement communications from an earlier criminal case regarding the marketing of OxyContin; and information regarding how sales representatives marketed the drug."

The Pike County case was a lawsuit filed in 2007 by then-Attorney General Greg Stumbo, alleging similar fraud and increased costs to the state for drug treatment and health care. It was transferred to federal court, where it lingered for several years under then-AG Jack Conway, who got it transferred back to Pike Circuit Judge Steven Combs. Depositions were taken, and in December 2015, as one of his last official acts, Conway settled the case and agreed to destroy 17 million pages of documents he had obtained through discovery.

However, some copies of the documents remained on file in Pike County, and Stat asked for them. in May 2016, Combs ordered them released, but stayed the order pending Purdue's appeal. He wrote, “The court sees no higher value than the public (via the media) having access to these discovery materials so that the public can see the facts for themselves.”

Jack Conway

Almost a year and a half after oral arguments in the case, the three-judge panel of the appeals court unanimously agreed, saying it was the only way to hold Conway accountable for his actions. Without naming Conway, Judge Glenn Acree wrote, “Some agent of the government compromised the claim against Purdue; i.e., some agent sold the people’s property. . . . Without access to court records, how can the public assess whether a government employee’s decision to compromise a valuable claim of the people adequately protected their interest or maximized the claim’s value?”

Conway told the Louisville Courier Journal Friday, “Kentucky got many times over what any state has gotten from Purdue Pharma. After eight and a half years, I thought it was best to get what we could. I hope it all comes out, (that) all of the documents eventually get released, and sooner rather than later.”

Purdue has 30 days to appeal. It indicated that it would, either to the state Supreme Court or through a rehearing by the appeals court. Either could refuse to allow further action.

“It's taken a long time, but we're now very optimistic that these records will see the light of day very soon,” Stat Managing Editor Gideon Gil, a former health reporter and regional editor for the Courier Journal, told Kentucky Health News.

Louisville lawyer Jon Fleischaker, who represented Stat, told the publication, “Really what the court is saying is these are public records. The public has an interest in them, and the public has a right to them.”

Stat Editor Rick Berke said, “More than two years after we filed this suit, the scourge of opioid addiction has grown worse, and the questions have grown about Purdue’s practices in marketing OxyContin. It is vital that that we all learn as much as possible about the culpability of Purdue, and the consequences of the company’s decisions on the health of Americans.”

If Ky. teenagers' use of e-cigarettes continues at its current pace, look for a new generation of adult smokers, conference is told

By Melissa Patrick
Kentucky Health News

Kentucky teachers have plenty to keep up with in the schools, which can cause an issue like teenagers' vaping of electronic cigarettes to get lost in the shuffle, but health advocates warn that if we don't get in front of this uptick in e-cigarette use, a new generation of adult smokers is on the horizon -- along with all of the health issues that come with it.

Eric Kennedy of the Kentucky School
Boards Association ( Foundation for a
Healthy Kentucky photo )

At a Dec. 10 Coalition for a Smoke-Free Tomorrow conference in Louisville, Eric Kennedy, chief lobbyist for the Kentucky School Boards Association, said KSBA offers districts a model policy for 100 percent smoke-free schools that includes e-cigarettes, and encourages them to adopt it. However, despite the e-cig epidemic in schools, it hasn't offered any specific guidance on the topic of e-cigs or Juul, a wildly popular e-cig that looks like an oversize USB drive and comes in popular flavors.

"I think there is a lot coming at classroom teachers on this and every issue, and it's not as streamlined as it needs to be, and that is a big part of what the coalition is working on," he said. "We're almost at a level of being overwhelmed, if not already beyond that point. . . . It's unfortunate that it's easy for an issue like this to get lost in the shuffle of the massive amounts of information coming at classroom teachers and superintendents and everyone else in the district. So I think that's something that we will keep working on, but that's always going to be part of the problem."

Many new school board members will take office in January.

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky and chair of the coalition, told the conference, "The enormity of this . . . surge is a recent phenomenon, so I don't think anybody has realized just how dire this issue is and how quickly it has become so."

Some may question the use of the word "dire," but teen use of e-cigarettes has become so prevalent that the U.S. Food and Drug Administration has called it an epidemic. Federal research shows that high-school students who reported being current e-cig users increased 78 percent between 2017 and 2018, exceeding 3 million. The same report showed use by middle schoolers increased 48 percent.

In Kentucky, about the same number of high-school students smoke cigarettes as use e-cigs, 14 percent. But health advocates at the conference warned that e-cig use is likely much higher among the state's youth because the survey was taken before the introduction of Juul and Juul-like products.

To get a more current understanding of what is going on in Kentucky, the foundation and Kentucky Youth Advocates conducted focus-group discussions in October with 35 Kentucky teens in Campbell, Clay, Jefferson, McCracken and Monroe counties about their knowledge, perception and usage of e-cigarettes in their schools.

"The kids asserted educators and parents were clueless about their use," said Terry Brooks, executive director of KYA. "And checking with parents and educators, they confirmed they were clueless. So, we've got a real adult/kid knowledge gap."

Catie Kelly, senior at Martha Layne Collins
High School, talked about e-cig use by teens.
(Foundation for a Healthy Kentucky photo)

Catie Kelly, a senior at  Shelby County's Martha Layne Collins High School, who was not part of the focus groups, told conference attendees that the flavors were the main reason kids are using e-cigarettes, and that most kids don't realize they are harmful or have nicotine in them. In fact, a Juul can have as much nicotine as a pack of cigarettes.

"It is so easy to use in school because it's so small and is really easy to hide. Most of my friends, they'll just put their head down and put it under their sleeve and then blow the smoke into their sweatshirt," she said. "People you wouldn't think would use a Juul would use a Juul." The device has 75 percent of the e-cigarette market.

Chandler offered four policy suggestions toward decreasing e-cigarette use among teens, including making sure e-cigs are included in all local ordinances and school policies; an excise tax parallel to regular cigarettes; the prohibition of flavors in e-cigs; and allowing cities and counties to enact stricter tobacco control policies than at the state level.

Asked why a statewide smoke-free school law wasn't listed as a policy priority on the news release, Chandler said it had inadvertently been left off. "One hundred percent smoke-free schools is what we intend to do," he said. "This whole boom of e-cigarette use I think has made this tobacco-free schools issue much more important and timely right now."

As of July, 72 of the state's 173 school districts (42 percent) have 100 percent smoke-free schools, covering 57 percent of the state's students. However, many of these districts still need to update their policy to meet new standards for e-cigarettes.

Rep. Kim Moser, R-Taylor Mill, said she also thought the surge in e-cigarette use among Kentucky's youth could spur the passage of a statewide tobacco-free school bill this year. Moser is the new chair of the House Health and Family Services committee and said she plans to file a bill for such a law.

But Sen. Ralph Alvarado, R-Winchester, new chair of the Senate Health and Welfare committee, said he wasn't so sure the epidemic would change things. "It's not a guarantee, but I'm hoping that with the new leadership in the House this coming year that this will loosen the tobacco policy up a little bit," he said.

Alvarado's tobacco-free school bill passed the Senate in 2017 but died in the House. Two such bills were introduced in the last session, but were not called up in the legislature's education committees.

Alvarado, a physician, said he will file the legislation again, but added that no matter how much science and data he has presented in the past to show the harms of smoking, it hasn't outweighed the philosophical argument for many that the government shouldn't be telling people what to do.

The KSBA's Kennedy said parental support for such policies to include e-cigs is vital, because many parents still "don't think they are a big deal" and often ask that their child not be reprimanded for using them. He said the problem is so rampant that it's not possible to suspend all student violators.

He said, "It's almost in some ways too late to get out in front of it, but of course that can't stop us from trying to do everything that we possibly can."

Other points from the conference:

• 80 percent of children are exposed to e-cigarette advertising.
• 85 percent of youth who use e-cigs report using flavored varieties.
• 40 percent of 18- to 24-year-olds who vape report never smoking a regular cigarette.
• One-third of youth who have ever used e-cigs report also using marijuana.
• Nine out of 10 adult smokers started smoking before they turned 18.
• 99 percent of e-cigs have nicotine; the rest are typically found in vape shops.
• The adolescent brain is "uniquely vulnerable" to nicotine addiction, meaning youth become addicted more quickly and smaller amounts of nicotine can create addiction.
• Nationwide, nearly 3 percent of adults use e-cigarettes and 21 percent of youth do; adult e-cig use in Kentucky is higher, 5.9 percent; 24.6 percent of Kentucky adults smoke.
• Research has not proven that e-cigs help smokers quit smoking.
• Research shows that kids who use e-cigs are more likely to smoke.
• E-cigs create secondhand aerosols with potentially harmful ingredients, including volatile organic compounds, ultrafine particles, heavy metals and potential cancer-causing agents.