Surge by a stronger strain of the flu is another warning that the season for the disease is not over; shots still available and useful

"Though influenza activity typically peaks by February’s end, the flu season isn’t over – and a harsher strain called H3N2 has increased in circulation both nationwide and in Kentucky," reports Caroline Eggers of the Bowling Green Daily News.

“Some people may think flu season is over, but it is not,” Glynda Chu, spokeswoman for The Medical Center at Bowling Green, told the Daily News in an email. “Many people in our area are suffering with the flu and we encourage everyone to please get a flu shot.”

Among the four types of flu viruses, "influenza A accounts for the majority of cases and is the only strain that is divided into subtypes, which are most commonly H1N1 and H3N2," Eggers notes. "Although the H1N1 virus has predominated this flu season, the H3N2 virus accounted for nearly half of influenza A detected nationally through the week of Feb. 16. In Kentucky and the Southeast, the H3N2 virus is considered predominant."

That calls for caution because H3N2 causes more greater number of hospitalizations and deaths in children and the elderly, according to the Centers for Disease Control and Prevention. The CDC recommends getting a flu vaccination even at this point, because the flu season won't end until May.

"Other methods of protection include frequent hand washing, especially before eating or touching the face, and avoiding touching public surfaces," Eggers notes. "If you suspect the illness, remain home from work, school or errands to prevent further spread, and consider getting tested at the hospital and starting antiviral medications. But mostly, the best treatment is plenty of rest and drinking lots of water."

Guthrie tries to preserve funding for Medicaid program that gets beneficiaries out of facilities and into community-based support

U.S. Rep. Brett Guthrie is working to find money to save a program aimed at moving Medicaid beneficiaries, mainly those with disabilities, out of facilities and into community-based, long-term support services they can get at home.

The "Money Follows the Person" demonstration program got only three months of funding in the latest appropriations bill because of its cost, reports Michele Stein of Inside Health Policy. Guthrie and his Democratic counterpart are co-sponsoring a bill for a five-year extension.

Guthrie (Ft. Collins Coloradoan photo)

Guthrie is from Bowling Green and represents the Second Congressional District. His role in the issue stems from his top rank among Republicans on the Oversight and Investigations Subcommittee of the House Energy and Commerce Committee.

The demonstration program began in 2007, and was funded by the 2010 Patient Protection and Affordable Care Act through September 2016. "While no additional funding was provided for the demo after September 2016, states could continue to use unspent funds," Stein reports. "A 2017 evaluation found the program to be popular and said [it] provided strong evidence that beneficiaries’ quality of life improves when transitioned back to the community."

The evaluation said the program had transitioned 71 older Kentuckians, 137 Kentuckians with physical disabilities, and 90 with intellectual or developmental disabilities. It reduced expenses for all three categories of beneficiaries, but the vast majority of the savings came in the third category.

But the program's cost is a challenge. Because of that, the Energy and Commerce Committee considered a one-year extension, rather than a five-year extension that had been proposed, and then the partial government shutdown intervened; new committee Chair Frank Pallone (D-N.J.) "said he didn’t want the program to be collateral damage from the shutdown," Stein reports.

On Feb. 25, Guthrie and subcommittee Chair Debbie Dingell (D-Mich.) introduced a bill to fund the program for five years, drawing endorsements from advocates for the poor and elderly.

“Money Follows the Person has been one of the most effective disability rights programs of the twenty-first century," said Vania Leveille, senior legislative counsel for the American Civil Liberties Union. "It offers people with disabilities a meaningful alternative to institutionalization and helps safeguard their autonomy, liberty and self-determination."

Matt Salo, executive director of the National Association of Medicaid Directors, said five-year funding has bipartisan support, and time to get through Congress, Stein reports: "He expressed hope the legislation would pass if lawmakers agree on how to pay for it."

Studies show that volunteer work helps your health; Kentucky's level of volunteerism depends on how you measure it

Foundation for a Healthy Kentucky chart; for a larger version, click on it

Most Kentucky adults are involved in some community activity, broadly defined, but the state ranks below average, 36th, in the latest state-by-state ranking of volunteerism.

"Volunteering can improve a community’s health and build connections between neighbors," says the Foundation for a Healthy Kentucky. "To learn more about volunteering and civic participation in the commonwealth, the 2018 Kentucky Health Issues Poll asked Kentucky adults whether they engaged in a variety of civic activities in the prior year. Seven of these activities were related to political engagement and three were related to community participation."

The poll found that 78 percent of Kentucky adults are involved in civic activities of some kind from volunteer work to talking about politics, and 68 percent are engaged in politics in some way, including an in-person discussion about politics and government. It found that 54 percent were active in their communities through volunteering at their church or other nonprofit group, working on a community project or donating blood.

"Getting involved can actually be a prescription for improving individual health as well as the health of our communities," said Ben Chandler, president and CEO of the foundation. "It's that 'helper's high' that occurs when we're contributing with no expectation of getting paid. Studies show this sense of purpose leads to lower mortality rates, reduced depression and better functionality."

In the latest ratings by the Corporation for National and Volunteer Service, which use narrower definitions than the Kentucky poll, only 23.5 percent of Kentuckians were considered volunteers. The state's volunteer rate has been declining since 2005, when it was above the national average.

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In the Kentucky poll, engagement varied by education level. Adults with more education were more likely than adults with less education to participate in each of the activities. In the past year, 89 percent of college graduates participated in a political activity, but that was true of only 37 percent of adults who had not graduated high school. Three-fourths of college graduates participated in community activities, but only 31 percent of high-school dropouts did.

 

KHIP is an annual telephone poll of Kentucky adults about health and health-policy issues; it is funded jointly by the Foundation for a Healthy Kentucky and Interact for Health, a Cincinnati-area foundation.

Health providers and advocates oppose Medicaid co-payment, say it creates barrier to care and administrative burden

By Melissa Patrick
Kentucky Health News

Health advocates at a regulatory meeting about the state's new Medicaid co-payment requirements said the new rule is riddled with problems, all of which they anticipated.

The co-payments, which range from $1 for some prescriptions to $50 for any type of inpatient service, went into effect Jan. 1 for most adult Medicaid recipients in Kentucky.

Jason Dunn, a policy analyst for Kentucky Voices for Health, said the coalition of organizations strongly opposes the co-pays, and reiterated many of the points made in a Dec. 11 letter to the Medicaid commissioner asking the state to reconsider implementing the program. The letter was signed by 26 groups.

Dunn said research shows that even small co-pays cause many low-income people to go without care, especially when they need ongoing care or multiple medications.

"The unintended consequences of creating barriers to care are too often offset by increased cost and more expensive care down the road," Dunn said. "In short, this is not a best practice and for that reason we are opposed to mandatory co-pays for Medicaid beneficiaries."

Pikeville dentist Bill Collins, a former president of the Kentucky Dental Association, opposed co-pays in written comments that were read at the meeting. He said his offices don't collect them, largely because of the administrative burden.

"Some of my peers have collected and had to reimburse the patient," he wrote. "This is not a simple task; bookkeeping is initiated, and costs are then upon the provider; the $3 co-pay then becomes a $5 to $10 return. The bookkeeping is a nightmare."

He added, "We as providers want to treat our patients, but no one, not even government can constantly lose revenue and stay in business. We feel with noncollectable copays, additional difficult administrative tasks, and the unknown of "my rewards dollars" make it difficult to accept."

The new co-pays are separate from the state's new Medicaid plan, called Kentucky HEALTH, which is set to roll out April 1, unless a court orders otherwise. When that plan begins, monthly premiums ranging from $1 to $15 per month will replace the co-pays for most beneficiaries. The plan will also require beneficiaries to earn "virtual dollars" to pay for vision and dental care, rather than getting the benefits as part of their basic package.

KVH also submitted comments it had collected from a survey about the mandatory co-payments. One respondent wrote, "We have chosen to get food and pay bills over medications and considering we both have health issues, including diabetes, this is making things rough."

Another wrote, "As I have 10 prescriptions I must fill each month, and most are not generically available, I am concerned about meeting my monthly bills since my co-pay will probably be around $30 monthly. I am already relying on a food bank to eat. I am elderly and disabled and cannot work."

Emily Beauregard, executive director of KVH, said the survey of 140 people found that 90 percent of them opposed the copays. The survey respondents included 23 Medicaid providers and 90 Medicaid beneficiaries, family members of beneficiaries, and others.

Beauregard said 21 of the respondents reported they couldn't fill prescriptions because they couldn't afford the co-pay, 30 said they were avoiding or delaying care, and many expressed concerns about rationing their care or having to make trade-offs between paying their bills.

Beauregard also gave several examples of people who were denied care because they couldn't afford a co-pay, but shouldn't have been because they were below the federal poverty level. A state regulation requires providers to see or treat such people even if they can't afford the co-pay.

"It's important to understand that in practice sometimes the safeguards we write into policies aren't always adhered to in practice," Beauregard said. "Providers may not understand them, their staff might not be aware or trained properly or they may simply may not be following the practice."

Is the Cabinet for Health and Family Services or its Department for Medicaid Services hearing about any of these issues from Medicaid providers and beneficiaries? Asked that question via email, cabinet spokesman Doug Hogan replied by saying that 39 other states have some sort of cost-sharing in Medicaid and it's important for beneficiaries to "plan for their health care visits and prepare to pay the minimum co-pay we require."

Hogan added that there are financial-planning resources, such as community-based advocacy groups, available to help Medicaid beneficiaries become better prepared to pay the "very minimal co-pay."

He said, "Kentucky taxpayers are spending thousands of dollars to fund health-care services for our recipients. Asking our recipients to pay co-pays that are, in most instances, $1 to $3, is a reasonable request for that healthcare that is worth thousands — and it helps prepare them for commercial market coverage in the event they move into that market."

The state has until March 15 to respond to the public comments.

Bill to raise legal age to buy tobacco products to 21 fails on 4-6 committee vote; bill's effectiveness questioned, called 'PR move'

Sen. Steve Meredith, center; Altria Group Vice President
David Fernandez, right; and Juul Labs lobbyist Jennifer
Cunningham spoke for a bill to raise the legal age for buying
tobacco products to 21. (Photo by Adam Beam, The Associated Press)

A bill to raise the legal age to buy tobacco products from 18 to 21 in Kentucky was voted down by the Senate Agriculture Committee Feb. 25, prompting a standing ovation from many in the room, Adam Beam reports for The Associated Press.

Friends and foes of tobacco both found things to dislike about the bill.

"Where I come from, tobacco is still king," said Republican Sen. Stan Humphries, a Trigg County tobacco farmer who then voted against the bill.

After the meeting, Ben Chandler, CEO of the Foundation for a Healthy Kentucky, called the bill a public-relations maneuver and said "The tobacco industry's PR move failed." He said such a bill should "include more severe penalties on retailers who sell these products to underage youth without taking reasonable precautions to verify age. By supporting a bill without these measures, the tobacco industry knows it will be ineffective" against "an epidemic of youth e-cigarette use in Kentucky and the nation that, in less than a year, has erased years of progress in protecting kids from nicotine and secondhand tobacco emissions."

Historically, the industry has opposed efforts to restrict tobacco use from people who older than 18, the age Americans can register to vote and join the military, but at least one company is supporting such bills as it "bets its future on e-cigarettes and other vapor products," Beam reports. Altria Group, the nation's largest tobacco company and the biggest spender among lobbying interests at the legislature, is buying a $13 billion stake in Juul Labs, by far the leading maker of an electronic cigarette that is the favorite of teenagers.

Altria Vice President David Fernandez told the committee, "Putting tobacco on par with alcohol makes sense and we do hope that doing that will also persuade policymakers to approach tobacco regulation a bit more reasonably." The week before, Altria's home state of Virginia had become the seventh state to raise the tobacco-buying age to 21.

Senate Bill 249's sponsor, Sen. Stephen Meredith, R-Leitchfield, pointed out the health reasons for it, including an oft-cited fact that tobacco-related illnesses cost Kentucky $2 billion each year, including $600 million in Medicaid expenses.

Committee Chairman Paul Hornback, R-Shelbyville, made an economic argument, warning that the Food and Drug Administration "could put Kentucky 'out of the tobacco business' with its potential rulings impacting the sale of e-cigarettes and other vapor products because of concerns about their impacts on youth smoking rates." But the bill failed on a vote of 4 to 6.

"Hornback indicated lawmakers could try to vote on the bill again before adjourning next month," Beam writes. "But it appears the bill, or any other tobacco-prevention bill, would have a tough time passing the state legislature." He notes that a bill to make all school properties and events tobacco-free has stalled in the House.

Ambulance runs for rural patients are 76% longer when their hospital closes, and for seniors, it's 98% longer, study finds

Rural and Underserved Health Research Center chart; click on it to enlarge

When a rural hospital closes, it's logical to assume that patients in its former service area will spend more time in ambulances getting to an emergency room farther away. A University of Kentucky study has figured out just how much more: "An estimated 11 additional minutes in an ambulance the year after a hospital closure in their ZIP code, a 76 percent increase compared to before the closure," reports UK's Rural and Underserved Health Research Center.

And it's even worse for seniors: "The times increased from 13.9 minutes to 27.6 minutes, a 13.7-minute or 97.9 percent increase," report researchers SuZanne Troske and Alison Davis. They noted that other studies have found that communities, rural and urban, where hospitals have closed "tended to have a higher percentage of elderly and poor residents."

The study is based on data from 2011 through 2014, with 73,000 ambulance calls and about the same number of hospital closures inside and outside metropolitan areas. The researchers found no change in transportation times in metro areas. Most of the closed hospitals were the only ones in their ZIP codes, but those areas are smaller in metros. "When hospitals close, rural patients requiring ambulance services are disproportionately affected," they write.

The researchers describe their methods: "Intuition suggests that patients are in an ambulance longer after the nearest hospital closes. However, no one has previously measured the travel time change. Our study is the first we are aware of that measures change in time in an ambulance based on reported ambulance trips." They noted that the study "should not be used to draw conclusions about transport times for rural patients who may have relied on a closed hospital but do not reside in the zip code of that closed hospital."

Addressing the implications for rural areas, Troske and Davis wrote, "More than half the hospitals in the country are located in rural areas and are the primary source of emergency medical services in these communities. When asked to rank attributes of rural health care facilities in a recent study, rural residents strongly valued access to emergency services through emergency departments s in their communities. . . . Access to emergency department services in communities, especially rural communities, persists as a priority for the Medicare program. In the 2017 annual report of the Medicare Payment Advisory Commission, the commissioners stressed the need to find more efficient and financially stable ways to deliver emergency services in rural communities. In the MedPAC report, they stated while there was reduced demand for inpatient hospital care, there was still need for emergency care among Medicare beneficiaries."

Tobacco-free schools bill is in trouble in the House; sponsor, a Republican, can't get enough of her party's members to be for it

By Melissa Patrick
Kentucky Health News

A bill to make all Kentucky school properties and events tobacco-free is in trouble in the state House, prompting advocates to mount a rescue effort.

Fifteen organizations took to social media and sent a letter to every representative asking for their support for House Bill 11, the statewide tobacco-free school bill,  including the Kentucky School Boards Association,

Rep. Kim Moser

“We respectfully urge the Kentucky House of Representatives to call HB 11 for a vote on the House floor as soon as possible," says the letter. "Please do not sacrifice the health of all of our school children to the convenience of fewer than a quarter of Kentucky adults who use tobacco."

The bill's sponsor, Rep. Kim Moser, R-Taylor Mill, told Kentucky Health News in a telephone interview that she still has hope it will get called up for a vote and is still working toward that end, but couldn't get any answers as to what was going on with it. She said she had heard it was going to be pulled from the House's orders of the day.

That would be a death knell for the bill, which passed unanimously out of the committee Moser chairs on Feb. 7 and was put on the consent calendar, used to pass bills without debate. Then it was moved to the regular orders, a switch that required signatures of three lawmakers: Reps. Lynn Bechler, R-Marion; Myron Dossett, R-Pembroke; and Reginald Meeks, D-Louisville. Meeks said he was for the bill but wanted it to be debated.

Rep. Suzanne Miles

Bonnie Hackbarth, vice-president for external affairs with the Foundation for a Healthy Kentucky, told Kentucky Health News that House Republican Caucus Chair Suzanne Miles of Owensboro is opposed to the bill. Moser said that she was not aware of that. Miles did not respond to a request for comment.

Opposition from one of the five leaders of the House's Republican majority is a danger sign for the bill, which is already under attack through floor amendments.

Rep. R. Travis Brenda, R-Cartersville, a Rockcastle County teacher, filed an amendment to allow use of tobacco products if children were not present, an effort likely meant to appease some of the bill's opponents. Moser promptly filed an amendment to clarify that the law, if passed, would prohibits smoking by all persons at all times on school properties, activities or trips.

Then Rep. Richard Heath, R-Mayfield, filed an amendment that would gut the bill and let local school boards make all decisions about tobacco use in their districts, as they already do. Rep. Lynn Bechler, R-Marion, filed an identical amendment the next day, Feb. 22.

Bechler who initiated the effort to move the bill from the consent calendar, told Kentucky Health News last week that he opposes the bill because it is government overreach. Rep. Myron Dossett, R-Pembroke, who also signed the petition, said likewise. He also spoke up for tobacco, noting that he represents Christian County, a large tobacco producer and home to a large smokeless-tobacco factory.

Moser noted that the opposition comes from members of her own party. "I think I have the votes in the House as a total to pass this," she said, "but if they are worried about there being more Democrats than Republicans, at this point they might be right -- and that's kind of sad." The House has 61 Republicans and 39 Democrats.

All the bill's active opponents but Brenda are from Western Kentucky, which has fewer school districts with 100 percent tobacco-free school policies (but not as many as in Eastern Kentucky). Most of the schools in Miles's district are already tobacco-free.

Overall, 74 of the state's 173 districts have adopted such policies, covering 740 schools and 58 percent of the state's students. Federal law only prohibits smoking inside schools that receive federal funding.

“It's just too bad, too bad for Kentucky," Moser said. "The whole thing is just beyond me as to why this is something that we can't pass in Kentucky."

Moser said Kentucky needs a statewide tobacco-free school law because of the "exploding rates of [youth] vaping and Juuling," which she said leads to an addiction to nicotine "that is priming their brains for future addictions." Further, she said it's a great way to prevent Kentucky's teens from becoming adult smokers, noting that 90 percent of adult smokers started smoking in their teens.

"People complain that we don't do enough about prevention, and this is a prime example of something that is great that we can do -- and they won't do it," she said.

The letter to the lawmakers also points to reasons to pass such a law: “House Bill 11, the tobacco-free schools bill, would create an environment where smoking cigarettes and e-cigarettes is not the norm, reduce youth tobacco initiation, provide positive adult role modeling, and protect students, faculty, and visitors from the harms of secondhand smoke and aerosol 24 hours a day, seven days a week."

Health advocates have also taken to social media. On Twitter and Facebook, the Foundation for a Healthy Kentucky writes: Parents, teachers, health advocates, business leaders, students: Don't allow #tobaccofreeschools bill to languish and die in the House. Urge your state representative to call HB11 for a floor vote today!

Hackbarth said the advocates are arguing that since the bill passed the House Health and Family Services Committee unanimously, and most Kentucky adults in a recent poll supported it, "It really deserves the right to be heard."

The latest Kentucky Health Issues Poll, taken in September and October, found that 87 percent of Kentucky adults supported such a law. Polls since 2013 have found strong support for the policy.

"This is a short session and we cannot afford to wait any longer," Moser said in the news release about the letter. "We won't let this bill die quietly. Our constituents deserve to see a floor debate and vote on this important health legislation."

The letter was signed by the foundation, the American Heart Association, the American Lung Association, Baptist Health, the Campaign for Tobacco-Free Kids, the Kentucky Cancer Foundation, the Kentucky Chamber of Commerce, the Kentucky Council of Churches, the Kentucky Equal Justice Center, the Kentucky Health Collaborative, the Kentucky Health Departments Association, the Kentucky Hospital Association, the Kentucky Medical Association, the Kentucky School Boards Association and Kentucky Youth Advocates.

The policy also has the support of the Kentucky Association of School Superintendents and the Coalition for a Smoke-free Tomorrow, a coalition of about 180 groups in the state.

Report on Medicaid pharmacy managers confirms they make a profit at the expense of pharmacies; calls for new payment model

A "long-awaited state report" on how pharmacy benefit managers are paid seems to confirm the suspicion that they "are reaping big profits from state Medicaid dollars at the expanse of pharmacies,"  Deborah Yetter reports for the Louisville Courier Journal. 

Pharmacy benefit managers, or PBMs, are the middlemen between insurance companies and drug companies.  They process about $1.7 billion a year in Kentucky Medicaid prescriptions.

The report, titled "Medicaid Pharmacy Pricing: Opening the Black Box," shows that last year Kentucky PBMs "took in $123 million through a practice known as 'spread pricing,' the difference between what the pharmacy benefit company pays the pharmacist and what it bills the state Medicaid program," Yetter reports.

The report, compiled by the Department of Medicaid Services and ordered by the General Assembly, shows that the $123 million represents a 12.9 percent increase over the previous year.

Sen. Max Wise

"I truly believe this was a very conservative number," said Sen. Max Wise, R-Campbellsville, who sponsored the legislation for the report to create more transparency in how the PBMs are paid.

Wise told Yetter that he believes more investigation is warranted: "I have full faith that we will continue to receive further data that will support what I have been saying since day one, the PBMs are taking full advantage of not only the pharmacies of this commonwealth but the taxpayers at large."

Medicaid Commissioner Carol Steckel, in a news release, said her agency will continue to monitor the matter: "This report represents the first step in introducing transparency to the pharmacy program. We have additional steps that we will need to take in order to make this program fully transparent."

Yetter writes, "Lawmakers grumble that the current system is not transparent because the state Medicaid program contracts with managed care companies that, in turn, subcontract with PBMs, which report to the managed care companies, not the state, and have not previously disclosed information about their operations."

CVS Caremark has most of the PBM business in Kentucky. Christine Cramer, a spokeswoman from CVS Health, told Yetter that managed-care organizations choose the "pricing model that best fits with their needs" and that spread pricing is a "common contracting model." She added that the money kept by a PBM isn't necessarily profit, but may also be used to fund services and patient programs.

Yetter notes that the report does not include mail-order prescriptions or the state's largest managed-care organization, WellCare, which has about 35 percent of the nearly 1.3 million Kentucky Medicaid enrollees. WellCare told the state it didn't have any data to report because it uses a different pricing model, which bills the state the same amount it pays the pharmacists.

The report recommended eliminating spread pricing and requiring PBMs to bill the state Medicaid program for what they actually pay pharmacists.

Independent pharmacists in Kentucky have long complained that the current PBM payment models threaten to put them out of business, Yetter reports.

"My business literally has been trashed by the low reimbursement rates of the PBMs in the past year," Trimble County pharmacist Jennifer Grove said in a letter to legislators. "I am faced daily with keeping the doors open or turning patients away because I lose money every time I fill their prescriptions."

Yetter notes that Ohio and West Virginia are also dealing with the issue.

To further address it, Sen. Jimmy Higdon, R-Lebanon, has filed Senate Bill 139 to create more oversight of such companies and to rein in some of their practices. It awaits a hearing in the Senate Banking and Insurance Committee.

Ky. officials rejected infectious-disease chief's plea to move faster against hepatitis A outbreak, now nation's largest and deadliest

As part of a package of stories about Kentucky's hepatitis A outbreak, which is the "worst this century, sickening nearly 4,100 and killing 40," Laura Ungar and Chris Kenning of the Courier Journal write that the "state could have done more to control it."

In an April 2018 e-mail obtained by the Louisville newspaper, Dr. Robert Brawley, the state's infectious-disease chief at the time, wrote to his health department colleagues: "Need to move faster. The virus is moving faster than we and [local health departments] are … immunizing persons.”

"Brawley argued that a powerful state response was needed: $10 million, including $6 million for a fusillade of 150,000 vaccines and $4 million for temporary health workers to help administer them. In an email, he also lobbied for a public health emergency declaration to bolster the case for more federal money," Ungar and Kenning report. "His urgent pleas went nowhere. And in the months that followed, Kentucky’s outbreak metastasized into the nation's largest and deadliest."

The Courier Journal found that Brawley's "aggressive recommendations" were rejected by his boss, 31-year-old acting Health Commissioner Dr. Jeffrey Howard. Now Kentucky's death toll from this outbreak is the highest in the nation.

"Amid limited state budgets, county staffing constraints and the availability of more than $220 million in local health-department reserve funds — he stuck instead to a $3 million state response," the CJ reports. "The state ultimately sent $2.2 million to local departments and declined to declare an emergency. In addition, county health departments added little to no staff to increase efforts to find and vaccinate drug users and homeless people."

Ungar and Kenning report that Kentucky "never tried strategies used successfully by some of the other 15 states who fought outbreaks with limited budgets," like seeking money from the state legislature, deploying "strike teams" of state health workers to counties, and immediately deploying state funds for the epidemic.

The article details the decision-making process of Howard, who stood by his decisions, though he did acknowledge that in retrospect he could have done some things differently.

"I wish I would've been more bold and said, 'Let's move into Eastern Kentucky,' as opposed to waiting, as we did," said Howard, who grew up in Appalachia. "As an Eastern Kentucky guy, it's heartbreaking to see this disease spread out in rural Kentucky. And I knew the struggles that they'd have once it started."

Adam Meier, secretary of the Cabinet for Health and Family Services, told the reporters that he stood by Howard's choices, saying in a statement that the "challenges Kentucky faced were less financial and more logistical in nature as it related to identifying and engaging the at-risk populations. While hindsight might provide more context for some things now, in retrospect there’s not a single decision that I’m aware of that was made in real time, with the information available at the time, that I would change."

But Brawley, who resigned in June, told the Courier Journal that much greater resources were needed to battle Kentucky's spread of hepatitis A and called the state's response "too low and too slow" for what has become "the worst hepatitis A outbreak in the United States in the 21st century."

He added, "Had the state hastened its vaccination efforts, it may have more quickly reduced the risk of the disease's spread and prevented acute cases, hospitalizations for about 50 percent of those cases, deaths and avoided millions of dollars in healthcare expenses for emergency department visits and hospitalizations."

Ungar and Kenning reported that several others in the health department agreed with Brawley's recommendations, including nurse Margaret Jones, manager of the state's immunization program. "We should have done more sooner," said Jones, who retired last summer. "If we had been able to get the vaccines out early, we may not have near as many cases or near as many hospitalizations. … He knew what to do. I think his advice should have been heeded."

Now, state health officials are hopeful the hepatitis A outbreak has crested. The number of new cases each week is down from 150 in early November 2018, averaging 87 a week this year. Officials said their plans in 2019 include "working to help local departments vaccinate more regularly at jails, increase vaccinations generally, enlist more federally qualified health centers to administer vaccines, and continue to push out federally funded vaccine to counties," the CJ reports.

The newspaper published four other articles on this topic on the same day.

Ungar tells the story of an Eastern Kentucky woman who learned she had hepatitis A, along with her existing hepatitis C, while getting treatment for her heroin and methamphetamine addiction. Another story covers how other states have responded to the outbreaks of the disease, reporting that since 2017, 16 states have had outbreaks, infecting more than 13,000 people. Another details how hepatitis A spread across Kentucky.

The final story, written by Kenning, chronicles the story of an Appalachian woman with a heroin addiction who said she didn't know about the highly contagious virus, and even if she had, she wouldn't have cared. "People who are addicted like myself, I really didn't care if I lived or died. So I (wouldn't have) really cared if I was infected with it," she said.

Poll finds those with dental insurance are more likely to visit the dentist, and insurance often depends on income

Nearly 60 percent of Kentucky adults saw a dentist in the past year, but 26 percent said they delayed dental care because it cost too much, according to the latest Kentucky Health Issues Poll.

"Good dental health is about more than an attractive smile; taking care of your teeth and gums and seeing a dentist regularly can help prevent a whole host of diseases that affect the entire body," Dr. Laura Hancock Jones, a Morganfield dentist, said in a news release from the Foundation for a Healthy Kentucky, a co-sponsor of the poll.

Jones, a member of the foundation's Community Advisory Council, also said, "Health policies that make comprehensive dental care affordable and otherwise improve access are critical to improving overall health in Kentucky."

The poll, taken Aug. 26 through Oct. 21, also found that people with higher incomes were more likely to have dental insurance, and those with dental insurance were more likely to have visited a dentist.

Of the 60 percent of Kentucky adults who reported having dental insurance, the poll found that 73 percent had household incomes greater than 200 percent of the federal poverty level; 55 percent had an income between 138 percent and 200 percent of the federal poverty level; and 41 percent had an income less than 138 percent of the federal poverty level.

It may be interesting to see what happens in next year's poll, after Kentucky moves to its new Medicaid plan on April 1. Right now everyone on Medicaid who earns up to 138 percent of the federal poverty level has access to dental care, but after April 1 everyone except children and those on Medicaid who are not part of the new plan will be required to accrue "virtual dollars" to use for dental-care benefits by completing certain qualifying activities.

While the poll found that fewer Kentucky adults who saw a dentist had dental insurance in 2018 than in 2012, the last time the poll asked this question, the conclusion remains the same -- people who have dental insurance are more likely to go to the dentist.

In 2018, 73 percent of the adults who had gone to the dentist reported they had dental insurance, compared to 27 percent who did not. In 2012, those numbers were 63 percent and 36 percent respectively.

Some good news is that the number of Kentucky adults who delayed or skipped dental care because of cost has dropped over the years, to 26 percent in 2018 from 37 percent in 2012 and 43 percent in 2009.

Ben Chandler, president and CEO of the foundation, pointed out that this is another example of how insurance coverage, which is known to improve overall health outcomes, is often not accessible to those with lower level incomes.

"This KHIP report shows that the people who can least afford dental screenings and other preventive care, let alone treatment for gum disease and other oral health issues, are also the least likely to have insurance to help cover the cost of that care," Chandler said in the release.

The poll is co-sponsored by Interact for Health, a Cincinnati area foundation. It surveyed a random sample of 1,569 adults via landline and cell phone. Its margin of error is plus or minus 2.5 percentage points.

Policy can often improve a state's health more than health care, says report offering 13 policies known to work; Ky. only does 6

By Melissa Patrick
Kentucky Health News

Improving a state's health outcomes and lowering healthcare costs often has less to do with health care and more to do with implementing a range of policies that are known to have long-term impacts on health, such as smoke-free policies and universal pre-kindergarten programs. So says a new report  which shows that Kentucky is only implementing six of the 13 suggested policies.

"The United States is spending more and more on health-care services to treat disease. Yet spending on the drivers of good health -- quality housing, healthy foods and education -- is stagnant," says the report from Trust for America's Health, Promoting Health and Cost Control: How States Can Improve Community Health and Well-being through Policy Change.

"Residents of other countries that have higher ratios of spending on social services to spending on health care services have better health and live longer despite the U.S. spending more money per capita on medical services than any other country," says the report. It analyzes state action on 13 policies that are known to have long-term impacts on health and are based in evidence that shows their effectiveness.

To create the report, researchers reviewed about 1,500 evidence-based programs and strategies and then chose the 13 that had the strongest health impacts, showed economic evidence of impact, focused on prevention at the community level, and could be implemented by state legislative action.

The detailed report identifies policies that leverage the connection between health and learning, promote healthy living through the built environment, foster healthy behaviors, support healthy and affordable housing, and create economic opportunities. In addition to the suggested policies to improve health, the report also offers complementary policies for each of these categories.

As of Dec. 31, 2018, Kentucky had implemented six of the 13 suggested policies: a competitive foods policy, which sets nutritional standards for schools; a tobacco tax (though it is well below the national average); an alcohol tax; a housing rehabilitation loan-and-grant program for low-and median-income families; and has fair-hiring protections that include a measure that is often called "ban the box," which removes conviction-history questions on job applications.

Also, Kentucky leads the nation in the number of syringe exchanges, which the report says offer a long-term return of $7.58 for every $1 invested, by lowering HIV rates and reducing treatment costs, plus tremendous savings for averting cases of hepatitis C, which is very expensive to treat.

That leaves seven policies for Kentucky to work on, from the report's point of view.

Kentucky does not have a universal pre-kindergarten program, which the report defines as publicly funded preschool offered to all 4-year-old children with no eligibility requirements. The report says that high quality pre-K education programs can generate $4.63 in benefits to participants, taxpayers and others for every $1 spent on such programs. Also, Kentucky does not require all schools to offer a school breakfast or lunch program.

Kentucky also does not have a statewide indoor smoke-free policy, and is not likely to get one in the near future, since Gov. Matt Bevin has said he believes this is a local issue. However, there has been some movement on a bill to make all school properties and events tobacco-free this year, but it's uncertain if it will pass since it's hit a snag in the full House over issues of "government overreach."

Also, Kentucky does not have an earned-income tax credit; policies that support paid sick leave or paid family leave; policies supporting the concept of "complete streets," an approach to transportation that addresses the needs of all road users, such as walkers and bicyclists; rapid "re-housing" laws, which help homeless people move quickly into permanent housing.

In a state that persistently ranks in the bottom 10 states for almost every health measure, and that for three straight years has shown a significant increase in the number of years of potential life lost -- a broad measure of overall health and life expectancy -- this report offers evidenced-based suggestions for policies that if enacted could make a real difference in the health and economy of the state.

“Action is imperative,” said John Auerbach, president and CEO of Trust for America's Health. “As a nation, we spend trillions of dollars a year on healthcare and yet Americans are getting less healthy. The solution is two-fold: direct more spending to prevention efforts and address the social determinants of health instead of their impact after someone is sick.”

The Robert Wood Johnson Foundation and Kaiser Permanente, a managed-care consortium, funded the report.

Apply by March 1 for expenses-paid rural-health fellowship to attend Association of Health Care Journalists conference

The Association of Health Care Journalists is offering fellowships to attend its May 2-5 conference in Baltimore, including one for reporters and editors working in rural towns and counties or who work for outlets serving a predominantly rural population. "Generally, this includes counties with populations below 100,000," AHCJ says.

March 1 is the deadline to apply. The fellowship covers the conference registration fee, a year's membership in AHCJ (new or extended), up to four nights in the conference hotel (Wed.-Sat.) if you live you live more than 50 miles away; and up to $400 for travel assistance (outside of 50-mile radius from the host hotel) and up to $100 (inside a 50-mile radius).

To apply, click here. If selected for a fellowship, you may be asked to write an AHCJ website blog post, take pictures or shoot video of a conference session. The fellowship is supported by the Leona M. & Harry B. Helmsley Charitable Trust.

Lobbyists and others create tracking tables that make it easier to keep up with bills; legislature also offers free 'Bill Watch' service

As the 2019 General Assembly moves into the second half of its session, it can be easy to lose track of the many health-related bills, but a contract lobbying group and a progressive media organization have bill trackers to make that easier.

A small part of the tracking table for health-care bills
(For a larger version of the image, click on it)

The Government Strategies tracking tables are broken down into several categories: education, energy/environment, general business, health care, health insurance, insurance and transportation. The bills are chosen by the lobbyists, so it's worth taking a look in every category.

For example, House Bill 11 and Senate Bill 27, the measures to make all schools tobacco-free, are in the "general business" category instead of health care or education.

Each list links to the bill number, names the sponsor, offers a short summary of the bill, and records the last action, which is updated nightly. Click here to see.

Forward Kentucky, which describes itself as a progressive "media operation," also offers a bill tracker on its website. In addition to a list of all bills, bills in committee and bills that have crossed over, this tracker offers a list of what Forward Kentucky considers key legislation. Click here to see.

Another way to track bills is to go to the Kentucky General Assembly website and click on "Bills." This will take you to a page where you can click on "Bill Watch," which will then require you to register in order to track the specific bills that interest you.

U of L publicly seeks partner to buy Jewish Hospital and affiliates

Map from U of L request for proposals for joint venture involving facilities of KentuckyOne Health

The University of Louisville has gone public with its search for a partner to buy Jewish Hospital and its affiliates, and is now seeking a joint venture that would manage them and the U of L hospital.

"U of L had to make a move, and quickly,' Grace Schneider writes for the Louisville Courier Journal. "The institution has provided physicians, researchers and medical residents to key lines of service" at Jewish and the Frazier Rehab Institute. "But the future of its programs, crucial to U of L's standing as a teaching hospital, were in jeopardy after Denver-based Catholic Health Initiatives announced in spring 2017 that it would sell unprofitable Jewish and other facilities in Louisville. It's failed to complete a sale." CHI "agreed late last year to re-up on an academic affiliation agreement between KentuckyOne and U of L that pays several millions of dollars. But the money won't keep flowing beyond the first half of this year."

Jewish and its affiliates are part of KentuckyOne Health, a group that is being disbanded. It has been in talks with BlueMountain Capital Management, an investment group, for more than a year. "KentuckyOne spokesman David McArthur said the organization remains in confidential discussions with both U of L and BlueMountain and is working to reach a sale agreement by June 30," Schneider reports.

U of L President Neeli Bendapudi said the university is "casting a wide net" to find a partner. "The joint venture's options could include acquiring Jewish and other KentuckyOne assets outright, although the request also lists leasing as a possibility," Schneider reports. 

New House health committee chair says she asked for the job because 'health care is too important to leave to chance'

Rep. Kim Moser in her Capitol Annex office (Photo by Al Cross)

By Melissa Patrick

Kentucky Health News

The new chair of the state House Health and Family Services Committee has been a legislator for less than two years and two months, but says she's uniquely qualified for the position because of her background in health care and her willingness to speak out about important issues. 

Rep. Kim Moser, a Republican from Taylor Mill, told Kentucky Health News that she asked to be considered for the chair's position after briefly toying with the idea of running for one of the five slots in the House Republican leadership, but realized that "surprisingly few" House members have a health background.

"I said, you know what, health care is too important to leave it to chance, so I really felt strongly about doing this," she said in an interview in her corner office in the Capitol Annex. "I'm really very happy right here. I think this is where I need to be." 

Moser is a registered nurse with a specialty in neonatal intensive care. She also served as the director for the Northern Kentucky Office of Drug Control Policy between 2014 and 2018, and remains on its board. 

Moser describes herself as a "fiscal conservative" and "very pro-life" and says it's no surprise that she ended up in politics since she grew up in a political home. Her father, Dr. Floyd Poore, is a longtime family practice physician who sought the Democratic nomination for governor in 1991 after serving as state transportation secretary and gubernatorial campaign fund-raiser.

Moser said her father remains a registered Democrat, and grinned when she said she is working on getting him to change that. "I tell him all the time that he's really a Republican because I grew up in that house and that's how conservative he really is," she said. 

Moser said her involvement in health advocacy and policy also influenced her decision to run for office and her desire to lead the health committee. She provided some legislative education for the Kentucky Medical Association as a volunteer, and had worked for the KMA Alliance and the American Medical Association Alliance, of which she is the immediate past president. 

"That, coupled with the Office of Drug Control Policy, I was working on addiction and medical legislative issues on a local, state and national level," she said. "And I just saw how valuable it was, first of all, to have influence in all of those spaces and understand how one affects the other."

Moser replaced 30-year representative Tom Kerr in 2016. She said when Kerr asked her if she was ready to run for office after he decided to not seek re-election, the stars must have been aligned because her youngest of five sons was a senior in high school and the time was right. This is Moser's second term from House District 64, which covers parts of Campbell and Kenton counties. 

"I love it," she said. "I love working with constituents. I love helping solve problems, and maybe that's just the nurse and mom in me, but it feels like a good fit right now. I grew up in it, and when I got here, I kind of felt right at home." 

Moser, 56, said she doesn't rule out running for a higher position, but isn't actively pursuing it. "This wasn't the plan and that's not my plan, but you never know what opportunities come your way," she said. "And again, if I feel like I can offer something, that is why I would do that." 

As a legislator, Moser said, it's important to look at the big picture and to not get bogged down in the details, which she said can lead to political polarization.

For example, she said it's important to make sure programs exist to support foster care and addiction treatment, but it's even more important to implement policies that address the underlying causes: "I like to take a broader, 30,000-foot view of things."

When people take a short view of a problem, she said, they "get stuck in their party's talking points and don't always look at what is best for the child, the family, the state and the return on investment, if you will, on implementing programs that really get to the underlying causes."

Moser noted that there are often "recurrent themes" that act as the underlying causes for many of the issues that plague Kentucky, such as adverse childhood experiences. She said it's important to look at these recurrent themes and address them through legislation. 

According to America's Health Rankings, Kentucky is in the top 10 states for adverse childhood experiences, with 27 percent of its children having experienced two or more stressful or traumatic events on a list of 10 -- such as physical abuse or substance misuse in the home -- that are proven to have a lasting impact on their health and well-being.  

Moser said she subscribes to the Republican belief that cutting taxes would improve economic opportunities for low-income Kentuckians, and the notion that "a rising tide lifts all boats." 

"The economic stability of our state has a lot to do with our workforce and all the issues that we know cause problems for individuals. Certainly we know that if folks don't have a job, then they can't provide for their families and this increases stress," she said. "So I absolutely subscribe to that." 

Moser said that as the chair of the House's health committee, she plans to work on finding ways to address the underlying issues that contribute to so many of the chronic diseases in the state -- like addiction, obesity and tobacco use. 

She has already gotten a statewide tobacco-free school bill out of her committee, but it has run into some opposition in the full House. Moser is the prime sponsor of the measure, House Bill 11.

She also said she will work on figuring out ways to improve access to care for mental health, which she said is currently under-treated. "Mental health issues affect addiction, poverty, school safety," she said. "The list is pretty endless."

This year's influenza vaccine is more effective than last year's; there's months left in flu season, and shots are available

Flu vaccinations are easy to get. (Photo from Livestrong.com)

This year's flu vaccine is more effective than last year's and up to three months remain in the current flu season, so experts advise those who haven't been vaccinated to do so.

"Preliminary figures released Thursday suggest the vaccine is 47 percent effective in reducing a person’s risk of becoming sick enough to need to see a doctor. A final estimate for last season showed the vaccine was about 40 percent effective. Even in a good year, the flu vaccine is never as effective as most other vaccines," Lena Sun reports for The Washington Post. This year's vaccine formula is "even more effective — about 61 percent — in children, who are among the groups most vulnerable to flu-related complications."

The estimates were released by the federal Centers for Disease Control and Prevention, which advises, "The vaccine can still prevent illness, hospitalization, and death associated with currently circulating influenza viruses, or other influenza viruses that might circulate later in the season. During the 2017–18 influenza season . . . vaccination was estimated to prevent 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 deaths."

Sun writes, "In a reminder of how deadly the respiratory virus can be, federal health officials estimate that as many as 16,000 people have died of flu this season, more than what would be expected so far in a relatively mild season." Flu season usually runs into May.

Gov. Matt Bevin says he would support a medical marijuana bill; prospects for that are better in the House than in the Senate

Gov. Matt Bevin greeted Lincoln County citizens before
his forum in Stanford. (Photo from The Interior Journal)

Gov. Matt Bevin said he would be "happy" to sign a bill that would legalize medical marijuana, depending on how it's written, Bruce Schreiner and Adam Beam report for The Associated Press.

Bevin spoke Feb. 12 at a community forum in Stanford. AP reports that he became emotional when he talked about his teenage nephew who died in 2016 after fighting "a very hard battle with cancer."

"There is incredible medicinal value associated with cannabis," Bevin said. He added that patients who could benefit from medical marijuana should have access to it "where it can be prescribed and regulated as we would other such drugs."

AP reports that the governor "was emphatic" when he said he he would not support a bill written solely to raise money for the state's general fund. "It should be treated the same as every other drug -- taxed no more or no less. To say that we're going to do this as a way to raise money is wrong," he said. Bevin said he did not support recreational marijuana in Kentucky and would not sign such a bill.

Several bills regarding medical marijuana have been filed during the current legislative session.

House Bill 136, sponsored Reps. Diane St. Onge, R-Fort Wright, and Jason Nemes, R-Louisville, would make medical marijuana legal in Kentucky. It has been assigned to the House Judiciary Committee. Nemes told the AP that the bill has strong support in the Republican-led House.

"I've been given assurances it is going to move and I hope that it will," he told AP. "If it does, it will pass" the House. However, Senate President Robert Stivers has said more research is needed.

Senate Bill 170, sponsored by Sen. Stephen West, R-Paris, is a companion bill to the House bill. ItIt was filed Feb. 12, but through Friday, Feb. 15, it had not been assigned to a committee.

House Concurrent Resolution 5, sponsored by Rep. Danny Bentley, R-Russell, asks federal officials to expedite research on medical uses of marijuana, which could lead to its removal from the federal list of drugs that have "no currently accepted medical use and a high potential for abuse."

Marijuana has been made legal for medicinal purposes in 33 other states, according to the National Conference of State Legislatures.

Half of U.S. adults don't know the five symptoms of a heart attack; Ky. ranks second in the share of the population who've had one

By Melissa Patrick
Kentucky Health News

About 50 percent of American adults don't know the five common symptoms of a heart attack, even though a heart attack happens about every 40 seconds in the U.S., according to a recent study.

The five common symptoms of heart attack are pain or discomfort in the jaw, neck, or back; feeling weak, lightheaded or faint; chest pain or discomfort; pain or discomfort in the arms or shoulder; and shortness of breath.

Other symptoms include unexplained tiredness and nausea and vomiting.

The study, published in the Centers for Disease Control and Prevention's Feb. 8 Morbidity and Mortality Weekly Report, found that while the number of U.S. adults who could list all five of these symptoms increased to 50.2 percent in 2017 from 39.6 percent in 2008, half the adults in the study couldn't name them. Nearly 95 percent knew to call 911 if someone was having a heart attack. The data came from the National Health Interview Survey.

The study found that knowledge about the five heart attack symptoms was lower among men, young adults, racial and ethnic minorities, and persons with less than average education.

Heart attacks happen when part of the heart muscle doesn't receive adequate blood flow. It's important to call 911 immediately if you or someone you know is having a heart attack because the more time that passes without treatment to restore blood flow, the greater the risk to the heart.

In Kentucky, 6.5 percent of adults reported having had a heart attack, according to the 2017 Behavioral Risk Factor Surveillance System annual survey. The national average was 4.2 percent. Kentucky ranks second highest for his measure, followed by West Virginia. The CDC reports that every year, about 790,000 Americans have a heart attack.

Click here for an interactive atlas of heart disease and stroke data for each county in Kentucky.

Coronary artery disease, or atherosclerosis, which is sometimes called hardening of the arteries, is the main cause of heart attack, the CDC says. The disease is caused by plaque buildup in the wall of the arteries that supply blood to the heart and other parts of the body, which causes the arteries to narrow over time and can partially or totally block the blood flow.

The CDC offers a list of things you can do to lower your chances of getting heart disease, including: eating a healthy diet, being physically active, maintaining a healthy weight, not smoking, limiting your alcohol intake, checking your cholesterol, controlling your blood pressure, managing your diabetes, having screening tests done that are recommended and taking medications to control your high cholesterol, high blood pressure or diabetes.

It's also important to find out who in your family has heart disease and to then share it with other family members and your health care providers because having close blood relatives with heart disease can also increase your risk of having a heart attack.

Passport sues state over reduced reimbursements, says officials are trying to kill Ky.'s only nonprofit Medicaid managed-care firm

Passport CEO Mark Carter testified before a legislative
committee in Frankfort last month. (Image from WDRB)

Kentucky's only nonprofit manager of Medicaid filed suit Friday against the state health secretary, alleging that he and the Medicaid commissioner are trying to put it out of business.

Passport Health Plan's suit in Franklin Circuit Court says the state's cuts in its Medicaid reimbursements "threaten its existence as a provider of Medicaid managed care health services to about 300,000 Kentuckians," Deborah Yetter reports for the Louisville Courier Journal.

Adam Meier

The suit alleges that Health Secretary Adam Meier and Medicaid Commissioner Carol Steckel have the company "slated for immediate execution" even though each of them have been in their jobs less than a year. The case was assigned to Circuit Judge Thomas Wingate.

The filing of the suit "follows extensive efforts to resolve the dispute with the state Cabinet for Health and Family Services over the cuts enacted last year," Yetter notes. "Passport and cabinet officials met last week to try to resolve the dispute after appearing before a legislative committee to discuss the matter. But the talks were unsuccessful, the lawsuit said."

Passport is one of five managed-care organizations that handle care "for most of Kentucky's nearly 1.4 million Medicaid enrollees. The other four are all national, for-profit health plans," Yetter notes.

Passport said the suit "is the necessary next step to ensure an adequate reimbursement to allow providers to serve our members, particularly those in the Louisville region. While we would prefer to resolve the matter in negotiation with state leaders, our fiduciary responsibility requires us to explore all options. Without an immediate rate adjustment, Passport Health Plan will face insolvency in 2019. This would be a terrible outcome for Louisville and for Kentucky as a whole."

Some advice for rural residents about getting to physical therapy: tap into your 'sheer cussed determination'

Living in a rural area makes it much harder to access physical therapy, to the point where "sometimes it takes sheer cussed determination and good neighbors to help get us back on our feet," Donna Kallner writes for The Daily Yonder. Kallner, a fiber artist living in rural northern Wisconsin, writes that she had a hard time accessing PT after she was hit by a drunk driver in 1998.

"For many people in rural areas, reaching these services might take a longer journey than the 52-mile round trip required where I live," Kallner writes. "More than 40 percent of rural residents spend more than 30 minutes traveling to rehab, compared to 25.3 percent of urban residents. And the distance is an even greater obstacle when you can’t drive yourself."

Some rural residents give up on much-needed PT because of the logistical nightmare involved. Kallner acknowledges rural residents' tendency toward independence, or "pure cussedness," as she calls it, and advises those who need PT to consider the following questions when deciding whether or not to do it:

• What are my options? Visiting nurses or telemedicine therapy might be available. 
• What would be required of me and my family, medically and financially? Medicare could pay for inpatient physical therapy.
• Is it something you want to do? Ask your doctor what the consequences will be for your quality of life if you don't do PT.

Once you commit to doing PT, Kallner advises patients to keep the following in mind:

• Communicate your PT goals clearly to your therapists, especially if you see different ones at some appointments. 
• Ask your physical therapist to explain if you don't understand something.
• Be honest with your physical therapist about whether you've done assigned exercises at home; they can tell anyway, and it affects your care. Bonus: if you have been doing your homework, you might not have to come in as frequently.
• Be realistic about what exercises you can do at home. If they've assigned you a lot of different exercises, review the whole list with your physical therapist and ask if you can discontinue some.

"Even with specialized rehabilitation services, it helps to throw some sheer, cussed determination into the mix," Kallner writes. "But that doesn’t mean you have to do it all on your own. Be honest with family, friends and neighbors about what you need, and grant them the blessing of letting them help."

Study says diet drinks associated with higher risk of stroke and heart attack in women who have gone through menopause

https://www.usatoday.com/story/news/nation/2019/02/14/study-warns-diet-drinks-pose-risk-stroke-heart-attack-older-women/2875278002/

Tobacco-free schools bill hits a snag; prospects still appear favorable, but floor leader Carney says 'Nothing is certain'

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- The bill to get tobacco out of all Kentucky schools has hit a snag.

House Bill 11 passed unanimously out of the House Health and Family Services Committee Feb. 7 and was put on the consent calendar, for bills to pass without debate. It was moved to the regular orders, a switch that required signatures of three lawmakers.

Rep. Lynn Bechler, R-Marion, said he initiated the effort to move the bill from consent. The other signatures came from Reps. Myron Dossett, R-Pembroke, and Reginald Meeks, D-Louisville.

All three told Kentucky Health News that they signed the petition because they thought it needed to be debated on the House floor before it was voted on, but they differed in the specifics. Meeks said he would support it, but Bechler and Dossett said it would be government overreach, and Dossett spoke up for tobacco.

Rep. Lynn Bechler

Bechler said, "I thought it was important enough to discuss, not just be passed because it came out of committee that way. I also think that the bill goes way too far. I have no problem should an individual school district, as I believe 42 percent have already done so, have instituted the policy. But I think it would be state government overreach if we were to force schools to do that."

Among the state's 173 school districts, 74 have adopted 100 percent tobacco-free policies, covering 740 schools and 58 percent of the state's students. Federal law only prohibits smoking inside schools that receive federal funding.

The bill's sponsor, Rep. Kim Moser, R-Taylor Mill, argued that the bill would allow school boards to set their own rules around implementation and regulation, giving them a sort of "local option."

Bechler added, "I think it is wrong if somebody who chews tobacco can't come out at half-time of a football game and go sit in his or her car at the back of a parking lot and throw in a chew. There is no smoke coming out, none of the kids would be aware of it, it's not presenting a bad example."

The bill would apply to all school properties and events. Rep. Travis Brenda, R-Brodhead, a Rockcastle County teacher, has filed a floor amendment that would allow use of tobacco products on school property if children were not present.

Rep. Myron Dossett

Dossett concurred with Bechler, echoing several of the same points. "A lot of school districts have already voted to do this and I'm a strong believer that this is one of those local issues," he said, adding that it's important for parents to teach their children about the dangers of tobacco.

Dossett also noted that he represents Christian County, a large tobacco producer. It is also home to a large smokeless-tobacco factory.

Bechler nor Dossett said they had  received calls from their constituents, educators or school employees in opposition to the bill.

In support of the bill, Meeks said it was important to pass because it will help to decrease teen smoking rates, which will contribute to a lifetime of better health outcomes for them. "I asked that it be pulled so that we can have that more robust discussion of the bill," he said.

Rep. Kim Moser

Moser said she was working hard to make sure all of the House members were educated on the intent of the bill. Further, she said this year's version of the bill does not include possession of tobacco products, but only tobacco use.

"We want to get it right and I think it will pass," she said. "We've got a lot of support -- outside of the questions here, statewide -- it is so supported."

Moser has said the bill has the support of the Kentucky School Boards Association, the Kentucky Association of School Superintendents, the tobacco industry and the Juul Labs, maker of the most popular electronic cigarette. The idea had the support of 87 percent of Kentucky adults in the Kentucky Health Issues Poll and the lobbying support of the Coalition for a Smoke-free Tomorrow, about 180 groups across the state.

The coalition said in a prepared statement Thursday, "A strong tobacco-free schools policy is essential to protect our youth from tobacco. Prohibiting tobacco use 24/7 creates an environment where tobacco use is not the norm, reduces adolescent and teen tobacco use, protects youth from secondhand smoke, aerosol and residue, and provides positive adult role modeling. . . . The proposed amendment to allow some to use tobacco on school property is unnecessary, and would result in a weak, ineffective bill."

Rep. Bam Carney

House Majority Floor Leader Bam Carney, R-Campbellsville, said he thought the bill had enough votes to pass and that he expects that he would call it up for a vote at some point, but added, "Nothing is certain."

Carney, an educator, added, "It is an issue that a lot of our caucus members, particularly in the rural areas of the state, not that they are opposed to it, but I think it is a fundamental question again about local control, letting locals make that call, which 42 percent have already done that. So I think that's the fundamental question is to whether or not locals should be able to do that."

Speaker David Osborne of Prospect said he and other leaders of the House's Republican majority had not taken an official position on the bill, but "I'm personally for it and it would be our intent to move it."

Sen. Ralph Alvarado, R-Winchester, who has filed a companion bill in the Senate, said he was "optimistic" that the House version of the bill would be passed in the Senate if they could just get it through the House. "That'll be the toughest part," he said.

The Senate passed a bill similar to Moser's in 2017, but it died in the House and such bills weren't even heard in the House and Senate education committees last year.