Ky. Hospital Assn. gets grant for emergency-room software that tracks patient histories from other sites; could thwart 'ER hopping'

By Melissa Patrick
Kentucky Health News

The Kentucky Hospital Association has been awarded a $250,000 grant to equip Kentucky's emergency departments with software designed to help physicians have access to patient information from multiple sources in real time.

The grant for the software, called EDie, came from Anthem Foundation, the philanthropic arm of Anthem Inc., a major health insurer.

“Information is a powerful tool in medicine, especially emergency medicine when life and death decisions must be made quickly,” Harold C. Warman, president of Highlands Regional Medical Center in Prestonsburg, the first hospital in Kentucky to go live with the software, said in a news release. “EDie instantly consolidates information from multiple sources that would otherwise take hours to obtain, and lets emergency physicians make faster, more informed clinical decisions.”

EDie works by collecting data from thousands of hospitals, urgent cares, clinics and health plans and then packages the data and delivers it to emergency room physicians in real time.

"In one concise report, the ED team can see patient history, visit summaries, medical providers, security events, and even care recommendations like preferred language and drug allergies," says the release.

The grant funds, combined with discounts from Collective Medical Technologies, a Salt Lake City firm that developed the software, will cover one year's costs for nearly every hospital in the state, said Ginger Dreyer, director of communications for the hospital association.

"There are also separate grants to pay the cost for small, rural hospitals to have access to the EDie solution," Dreyer said.

The release says 10 Kentucky hospitals have adopted the technology and 28 others are in the process of installing it.

Dreyer said six five of the 10 that have adopted the program are actively using it, In addition to Highlands Regional, they are Breckinridge Memorial Hospital in Hardinsburg; Hardin Memorial Health in Elizabethtown; Wayne County Hospital in Monticello; and St. Claire Regional Medical Center in Morehead. ; and Twin Lakes Regional Medical Center in Leitchfield.

The release notes that this software will help hospitals identify and support high-risk patients across care settings, with the goal of reducing avoidable readmissions and further enabling statewide efforts to address the opioid epidemic,

“One particularly powerful application of this technology is in fighting Kentucky’s opioid epidemic,” KHA President Nancy Galvagni, said in the release. “Emergency-room hopping is a serious obstacle in helping people suffering from addiction and this software can tell a treating physician if the patient has a history of ER visits for pain treatment. EDie can be the difference between enabling addiction and treating it.”

One Affordable Care Act insurer in Kentucky wants a 12% rate hike next year; the other one has asked for a decrease of 4.5%

By Melissa Patrick
Kentucky Health News

One of the two insurers offering government-subsidized individual health plans in Kentucky for 2020 is asking for a 12 percent increase, while the other is asking for a 4.5% decrease.

Insurers offering plans for small groups under the Patient Protection and Affordable Care Act are asking for average hikes of 10.5%. These overall percentages reflect an average that will vary, depending on whether individuals smoke, how old they are and where they live.

Anthem Health Plans of Kentucky requested an average 12% increase for the 13 plans to be offered.

CareSource Kentucky requested an average rate decrease of 4.5% for its 12 individual plans.

The requests are preliminary and subject to change. The Kentucky Department of Insurance can approve, lower or raise the rates. The department said in a press release that it expects to finalize the rates by August, which is also when it will finalize any expansion of the plans' service areas.

This year, Anthem offered plans in 93 of the 120 counties, and CareSource offered plans in 61. In 34 counties, both insurers offered plans, but in 16 of those the Anthem plans have a narrow network of providers.

“From our initial review, it appears that the popular silver and bronze plans offered by both insurers receive either a much smaller average increase or comprise the majority of the decreases when compared to other plans,” Insurance Commissioner Nancy G. Atkins said in the release. “Over 90% of the participants select one of these plans, and we anticipate this trend to continue.”

Last year, Anthem asked for an average 3.5% increase and CareSource asked for a 19.4 % hike. The Insurance Department gave Anthem a higher increase than it asked for at 4.3% and CareSource got the 19.4% it requested.

Kentucky saw 84,620 residents enroll in subsidized coverage via Healthcare.gov during the open enrollment period for 2019. That was a 5.5% decrease from 2018, when 89,569 Kentuckians enrolled, but up 4.3% from 2017, when 81,155 enrolled. Kentucky has yet to reach the same number of enrollees as it did in 2015, when 106,330 enrolled. The state shifted enrollment to the federal exchange in 2016, away from the state-based exchange called Kynect. Open enrollment for 2020 begins Nov. 1.

State Sen. Ralph Alvarado, Bevin's running mate and a physician, agrees with him that state shouldn't require kids to be vaccinated

State Sen. Ralph Alvarado and Gov, Matt Bevin bumped fists
as they filed in January. (Photo: Mark Mahan, Lexington Herald-Leader)

Gov. Matt Bevin's running mate for lieutenant governor told a Northern Kentucky Tea Party group June 27 that he agrees with Bevin on immunization policy, that government shouldn't require children to be vaccinated.

State Sen. Ralph Alvarado of Winchester, a physician, said “I think it’s good health policy to administer vaccines, but if people don’t want them, we shouldn’t force people to take them.”

Alvarado was recorded by American Bridge, a group supporting Democratic Attorney General Andy Beshear for governor. The group posted the recording on YouTube. A transcript of his remarks is available here.

Alvarado "was responding to a question about a student in Northern Kentucky who had been pulled out of school for refusing to get the chickenpox vaccine," reports Daniel Desrochers of the Lexington Herald-Leader. "The debate over vaccines has captured national attention as the anti-vaccine movement has contributed to a rise in measles cases in the U.S."

Alvarado said, “I think it’s a very fine balance. I don’t think we should force anybody to do something they don’t want to do to their own bodies. We are seeing outbreaks, you’re seeing measles outbreaks and other things that are happening and a lot of people forget that a lot of these diseases can be fatal.” 

Asked about “all the kids who are dying from vaccines,” Alvarado said, “Again, we could debate a lot of that. That’s been studied . . . but to your question, you should have the right to say no if you don’t want that for your kids.” Desrochers notes that the World Health Organization says “so few deaths can plausibly be attributed to vaccines that it is hard to assess the risk statistically.”

Bevin said in a radio interview in March that he had exposed his children to chicken pox to immunize them. “If you are worried about your child getting chickenpox or whatever else, vaccinate your child,” he said. “But for some people, and for some parents, for some reason they choose otherwise,” he said. “This is America. The federal government should not be forcing this upon people.”

The federal government does not force states to require vaccinations, only recommends that they do. The National Conference of State Legislatures says all 50 states have laws requiring specific vaccines for students; 47 grant religious exemptions and 18 allow philosophical exemptions.

Kentucky only allows medical and religious exemptions. In 2017 the Bevin administration made it easier for parents to invoke the religious exemption. They can now download a form, have it notarized and submit it to their school upon enrollment, instead of having to get a signed form from a health-care provider. Spectrum News reported that the number of Kentucky parents claiming the religious exemption increased 59 percent in the 2017-18 school year.

A Cabinet for Health and Family Services representative told legislators in 2017 that the changes had been in the works for several years, in response to complaints that a medical entity should not have authority over a religious exemption; that a co-payment was often required to get a provider’s signature; and that parents and guardians were having trouble finding providers to sign the forms.

Assertions that governments shouldn’t require vaccinations don’t take into account the principle of “herd immunity,” which occurs when enough people have been immunized against a disease to protect others who are not immunized. Some are not immunized because their immune systems are too weak to allow them to be vaccinated, or because they are too young to be vaccinated.

People with weakened immune systems include those with cancer, especially if they are being treated with an aggressive chemotherapy, people who have had bone-marrow transplants, people who have had an organ transplant, people with auto-immune disorders, like rheumatoid arthritis or Lupus, or people with acquired immunodeficiency syndrome, or AIDS.

“Those people are absolutely reliant upon herd immunity because we can’t immunize them,” Dr. Sean McTigue, an infectious disease specialist at the University of Kentucky, told Kentucky Health News in March. “The only way that we have to protect them is to ensure that everybody around them is immunized so that the chances of them actually coming into contact with somebody who has one of these very infectious viruses or bacteria is very, very low.”

McTigue said herd immunity is vitally important to protect babies, because they can’t be vaccinated for measles, mumps and rubella or chickenpox until they are a year old because these vaccines are made with very weak, but live viruses.

“So, every single baby less than one year old is unvaccinated and unprotected against those conditions,” McTigue said. “And the young babies who cannot yet be immunized against those conditions are exactly the patients that we worry about the most if they get those infections because they are at greatest risk of complications.”

Program that addresses childhood trauma and teaches resilience shows results in Louisville; expanding to Lake Cumberland area

By Melissa Patrick
Kentucky Health News

A pilot program in a few Louisville elementary schools that focused on building resiliency in children who suffer from childhood trauma saw results: fewer with behavior referrals, improved staff skills, increased parental participation and increased teacher retention -- and it's a model that could be replicated.

Studies show that adverse childhood experiences, a term used for all types of abuse, neglect and family dysfunction that occur under the age of 18, are linked to negative health outcomes in adulthood.

ACEs have been linked to chronic health conditions, like heart disease and obesity, risky behaviors, like substance abuse, mental-health issues, like depression, and even early death.

When determining if a child has experienced trauma, 10 types of ACEs are measured, largely because they are the ones that children experience most often.

They include five personal measures, including physical, verbal and sexual abuse and physical and emotional neglect. The other five relate to other family members: having an alcoholic parent, a mother who is a victim of domestic violence, a family member in jail, a member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment.

The more ACEs a child experiences, the greater his or her chances of experiencing poor health outcomes in adulthood. Nearly 27 percent of Kentucky's children have two or more ACEs.

ACEs are the root cause of many serious academic, social and behavioral problems that have the potential to prevent a child from succeeding in school, and as noted before, more than one of four children in Kentucky are showing up to school having experienced two or more of them.

The pilot program in Louisville, called the Bounce Coalition, was created to address this trauma. It was funded in part by a six-year, $300,000 grant from the Foundation for a Healthy Kentucky that was matched by local funds.

"Abuse, neglect or situations such as parental drug use or incarceration that kids experience not only cause many of them to act out. It may mean they'll have poor health as adults that could lead to an early death," Ben Chandler, foundation president ad CEO, said in a news release. "This grant program was about finding ways to mitigate the impact of ACEs early on, while patterns can be changed, with the goal of preventing both the short-term and the long-term problems ACEs create."

Bounce program participants Foundation for a Healthy Ky. photo)

The Bounce Coalition trained teachers and staff in several Louisville elementary schools to recognize ACEs and gave guidance on how to address them. It taught students strategies to promote resilience and included activities for parents. It also expanded its work to organizations outside the school setting.

The release notes that the program's trauma training is built around an approach of "What happened to you?" instead of "What's wrong with you?"

An evaluation of the two schools that implemented the program the longest showed improvements in student suspensions and behavioral referrals; a 56-point jump in the percentage of staff who felt they were adequately trained to deal with trauma, from 30% in 2014 to 86% in 2017; an increase of 195% in parent-teacher conferences between 2014 and 2017; and PTA membership grew from zero to 213.

The schools also showed improvements in all nine categories of their student school climate surveys, while the control school failed to show gains for any of the measures, and the district showed gains in five. And teacher retention in those schools increased to 90.2% in 2017, from 87.8% in 2014.

"Bounce has shown us that adults have the ability to change children's lives by re-framing their interactions," Betty J. Adkins, co-lead of the project, said in the release. "Children need at least one caring adult to believe in them. It is really that simple."

The Bounce Coalition is expanding its work to rural Kentucky to see if the same training will be beneficial there. Bounce received a two-year $200,000 foundation grant in May to work with Russell County Schools and the Lake Cumberland District Health Department to implement the ACEs program there.

Chandler said, "Our goal is to create a blueprint for successfully addressing ACEs that coalitions across Kentucky can use to secure funding from other sources to implement in their own school districts and communities."

Picnic season has arrived, which calls for extra food-safety steps; CDC offers four rules to follow: Clean, Separate, Cook, Chill

By Melissa Patrick
Kentucky Health News

Summer picnic and barbecue season is in full swing, which also means it's the season for an uptick in the number of people who get food borne illnesses, which most people call food poisoning.

According to the Centers for Disease Control and Prevention, each year in the U.S., about 48 million, or one in six, people get ill, 128,000 are hospitalized, and 3,000 die from foodborne disease.

All of those people didn't get sick at a picnic, but foodborne illnesses increase in the summer, largely because the bacteria that cause such illnesses multiply faster in warmer temperatures and preparing food outdoors makes safe food handling more difficult.

One problem is that most of us give little thought to how our food is stored, prepared and handled at these fun summer events, let alone if those preparing our food are washing their hands -- but we should, because it only takes one small mishap to sicken all of  the guest.

CDC graphic

The CDC and the state health department offers four simple rules to decrease the likelihood of anyone getting a food borne illness when eating outdoors: Clean; Separate; Cook; and Chill.
.
Clean: Wash your hands and clean your work and dining surfaces. If there is not a source of safe drinking water at your outdoor location, bring enough water for both preparation and cleaning. Otherwise, make sure you bring wet, disposable washcloths, wipes, or hand-sanitizer. Wash your hands both before and after handling any raw meat.

If you are serving multiple meals in an outdoor setting, take a lesson from seasoned campers and bring three large pans, biodegradable dish soap, bleach and plenty of extra water to set up a cleaning station. Pan one is the wash pan, with hot water and a few drops of soap; pan two is for a hot-water rinse; and pan three is for a sanitizing soak, with a small amount of bleach added to kill bacteria.

Separate: Cross-contamination during preparation, grilling and serving food is a prime cause of foodborne illness. To minimize this risk, wrap raw meats securely to keep their juices away from all other food; throw out marinades and sauces that have touched any raw meat; and remove cooked meat from the grill with clean utensils and place it on a clean plate.

Cook: The best way to ensure that meat is cooked hot enough to kill harmful germs is to use a food thermometer. Temperatures for beef, pork, veal and lamb needs to be 145° F, with a stand-time of three minutes at this temperature; 145° F for fish; 165° F for poultry and all pre-cooked meats, like hot-dogs; and 145° F for fish. After cooking, meats need to be kept at 140°F or warmer until served. Grilled foods can be kept hot by moving it to the side of the grill rack away from the coals.

Chill: Keep all meats at 40°F or lower in an insulated cooler with ice or frozen gel packs. Pack canned beverages in one cooler and food in another, since the beverage cooler is likely to be opened frequently. Meat, poultry, and seafood can also be packed while still frozen so that they stay colder longer. When driving, keep the cooler in the coolest part of the car and once outside place it in the shade if possible. Bring extra ice and pack it in a separate cooler. Don't use loose ice used to keep food cold in beverages.

The CDC also notes that it's important to not let food sit out for more than two hours, and if the temperature is 90°F or above, it should sit out for no more than one hour. One way to keep track of how it's been sitting out is to bring a timer, or set a timer on your cell phone. And it's not just meats; all perishable food should be monitored closely, especially salads made with mayonnaise or anything dairy-based. And a good rule of thumb: If you have any doubt, throw it out!

The health department also warns that if you clean your grill using a wire-bristle brush, check to make sure that no detached bristles have made their way into grilled food.

The CDC says symptoms of food poisoning can range from mild to severe and may differ depending on the germ you swallowed, but the most common ones are: upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever. Symptoms may take hours or days to develop, and can be life-threatening. And see a doctor if you have severe symptoms that include blood in your stool, fever over 102 degree, frequent vomiting, dehydration and diarrhea that last more than three days.

National foundation study estimates Medicaid work rules would lead to 86,000 to 136,000 in Ky. losing coverage the first year

Commonwealth Fund chart, adapted by Kentucky Health News; click on it for a larger version

If Kentucky and eight other states persuade federal courts to let them add work requirements to their Medicaid programs, Kentucky would lose more people from its Medicaid rolls than any of the states but Michigan, says a study by The Commonwealth Fund, a New York City-based foundation.

"These are losses only associated with the work requirements, and do not account for other elements like monthly premiums or new paperwork requirements that may trigger additional losses," researchers Leighton Ku and Erin Brantley write for the fund, which says it exists to "promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable and the elderly."

Ku is director of the Center for Health Policy Research, and Brantley is senior research associate, in the School of Public Health at George Washington University in Washington, D.C.

They write, "Most adult Medicaid beneficiaries work or are limited in their ability to work because of health problems, schooling, child care, or other needs. Many who would lose Medicaid eligibility are working or trying to work, but are unable to comply with the rules because they face major barriers to steady employment or cannot navigate the procedural barriers."

Kentucky officials have estimated that the state's Medicaid rolls would have 95,000 fewer people in five years with their plan than without it, in large measure from noncompliance with reporting requirements. (Tens of thousands of Kentuckians go on and off Medicaid each month as they become eligible or ineligible; the income limit is 138 percent of the federal poverty line: $17,236 for an individual and $35,535 for a family of four.)

The researchers estimated that the losses in Kentucky would be much greater; 86,000 to 136,000 merely in the first year, assuming full implementation of the program. That is based on an estimate that the state's "community engagement" requirements for "able-bodied" beneficiaries would affect up to 331,000 of the approximately 450,000 on the expanded version of Medicaid. That is higher than other estimates; the study estimates a loss of 26 to 41 percent in the expansion population.

In Arkansas, the only state that has terminated people for not complying with work rules, 18,000 lost coverage in the first six months before a federal judge blocked the program. He has also kept Kentucky from starting its program. The rulings have been appealed.

Many in Arkansas lost coverage "in large measure because of confusion about the policies," wrote the researchers, citing a recent study. "One-third did not know about the requirements; only half of those who were eligible and needed to report work activities were doing so. Arkansas’ work requirements were not associated with increased employment," which advocates say is an objective of the program.

Kentucky officials say they don't expect the state to see the results Arkansas did, largely because they have an aggressive outreach campaign and are committed to changing tactics if they see too many dropping off the Medicaid rolls. They say Kentucky's rollout has been longer than that in Arkansas, giving more preparation time; and they have strategic partners committed to the program's success, such as the Foundation for a Healthy Kentucky, employers and regional workforce boards.

Seven other states have federal authorization for work requirements: Arizona, Indiana, Michigan, New Hampshire, Ohio, Utah and Wisconsin. They "are either just starting to phase in their programs or have not yet begun to do so," James Romoser reports for Inside Health Policy. The study "is based on the initial coverage losses that occurred in Arkansas . . . as well as the national effects when similar work requirements were added to the Supplemental Nutrition Assistance Program" and policy differences among the states. "The smallest impact is expected in Wisconsin, because its waiver permits 48 months of non-compliance before beneficiaries are penalized. As a result, the researchers said significant coverage losses due to work requirements might not occur in the first year."

Seven of the nine states have imposed work requirements for SNAP, once called food stamps, and "should have been aware of consequences of work requirements after seeing how they worked" in SNAP, the researchers write. "Within 12 months, participation fell by 440,000. Several rigorous studies found that SNAP work requirements reduce enrollment and have little to no employment benefits."

The director of Kentucky's program, Kristi Putnam, says Medicaid and SNAP offer different benefits and should not be compared. She told Kentucky Health News that because American health benefits are typically tied to hours worked, it is important to help Kentuckians learn that system.

McConnell bill to raise tobacco age to 21 passes first hurdle, without controversial portion requiring states to follow suit

By Melissa Patrick
Kentucky Health News

U.S. Senate Majority Leader Mitch McConnell's bill to raise from 18 to 21 the nationwide minimum age to buy all tobacco products, including electronic cigarettes, has passed the Senate health committee, with a compromise removing the original requirement for states to pass their own "Tobacco-21" laws.

“I’m grateful to my colleagues for advancing our legislation to help curb the spike of youth tobacco use,” McConnell said in a news release. "Because children are extremely vulnerable to becoming addicted to nicotine and suffering its lifelong consequences, we must do everything we can to keep these products out of their hands."

 The bill is co-sponsored by U.S. Sen. Tim Kaine, a Democrat from Virginia.

 In Kentucky, about one in four 10th and 12th graders and one in seven eighth graders vaped in 2018, according to the 2018 Kentucky Incentives for Prevention Survey.

 The bill is now part of a 246-page amendment to the proposed Lower Health Care Costs Act of 2019, which includes legislation on a long list of health topics, including ending surprise medical bills, reducing the prices of prescription drugs, improving transparency in health care, improving public health, and improving the exchange of health information.

The Campaign for Tobacco-Free Kids opposed the original version of the bill, which included state law requirements, but supports the bill with the compromise legislation included.

"This compromise legislation raises the tobacco age to 21 nationwide and provides incentives and support for states to conduct enforcement, but it does not require that states pass laws that tobacco companies could use to block local tobacco regulations, including much-needed prohibitions on flavored tobacco products that entice and addict kids," the organization said in a June 25 news release.

The campaign added, "As this legislation moves forward, we urge Congress to maintain this important change and ensure the Tobacco 21 provisions are not weakened."

The concern about the original provision to require each state to pass its own Tobacco-21 law was that it put federal substance abuse block grants at risk if states didn't do so. Further, opponents of this provision worried that it would weaken state and local efforts by providing an opportunity for the tobacco industry to add special-interest provisions to state laws.

The tobacco industry, which is moving into electronic cigarettes, has supported a higher legal age to purchase tobacco products as a way to reduce pressure for youth-oriented regulations.

As of June 20, 16 states had already raised the tobacco age to 21, along with Washington, D.C., and at least 470 localities, according to the Campaign for Tobacco-Free Kids. It notes that the strength of each law "varies substantially."

Such a bill was introduced in Kentucky during the last legislative session, but failed to get out of the Senate Agriculture Committee.

 An editorial in The Winchester Sun applauds the concept of raising the legal age, but adds that McConnell's bill doesn't do enough, and suggest that this piece of legislation should simply be an "opening bid."

 "Public outcry over companies making money by selling flavored addiction juice to kids has forced those companies and their supporters to the table," the editorial says. "National T-21 legislation is their dream scenario. The legal age to buy e-cigarette products is already 18, so the law extends that prohibition by three years. In exchange for those three years, they want to be free to make their products as addictive and enticing as possible, including in ways that might appeal to minors."

The McConnell press release provided a list of nearly 60 organizations that support his bill, 10 from Kentucky: the Foundation for a Healthy Kentucky; the Kentucky Chamber of Commerce; the Kentucky Hospital Association; the Kentucky Medical Association; Kentucky Youth Advocates; the Kentucky Academy of Child and Adolescent Psychiatry; CHI Saint Joseph Health; the Kentucky Chapter of the American College of Cardiology; St. Elizabeth's Healthcare in Northern Kentucky; and Hosparus Health. 

The foundation, KYA and Kentucky Voices for Health published an op-ed endorsing the bill, along with the Kentucky School Boards Association, the Kentucky Cancer Foundation, the American Heart Association, the American Lung Association, the American Cancer Society Cancer Action Network, the Drug Free Clubs of America, the Northern Kentucky Chamber of Commerce and the Children’s Home of Northern Kentucky Behavioral Health. 

 Even though "tobacco-21 laws directly affect those who are 18 to 20 years old, the largest proportionate reduction in the initiation of tobacco use will be among adolescents ages 15 to 17," the op-ed says, citing a March 2015 report from the Institute of Medicine. The report concluded that "raising the national age to 21 would immediately improve adolescent health, decrease smoking by 12 percent nationwide and prevent hundreds of thousands of premature deaths."

 The op-ed adds, "A key reason tobacco-21 works is that most youth get tobacco products from friends and family members, rather than purchasing the products themselves. It’s much more common for adolescents and teens to hang out with those who are at or near their own age, than to have friends who are 21 or older. Thus, raising the legal sale age for tobacco products to 21 cuts off a major social source of tobacco for adolescents and teens."

This story has been updated to correct an error.

At opioid summit, Chamber urges employers to update policies, continues lobbying to reduce penalties for simple possession

The Kentucky Chamber of Commerce is calling on the state's business community to update its drug and alcohol policies to bring more help to their employees who suffer from addictions, and keep working to get state legislators to downgrade criminal penalties for simple drug possession.

Kentucky Chamber of Commerce President and CEO
David Adkisson spoke at the Chamber's opioid summit.

At an "opioid summit" in Lexington June 24, the business lobby also announced that its Kentucky Chamber Workforce Center has won about $700,000 to identify how businesses can prevent opioid addiction in the workplace and help employees recover, Rebekah Alvey reports for the Lexington Herald-Leader.

The Kentucky Office of Drug Control Policy put up $350,000 for the program, and private donors matched it.

The center's director, Beth Davisson, said the "Opioid Response Program for Business" will work with employers to provide free audits of human-resource policies and procedures related to addiction and recovery, with a long-term goal of connecting them with recovery programs. The grant will also fund a 15-month study of how the epidemic is affecting the workforce.

Kentucky Health Secretary Adam Meier told the group that it's important to be able to show companies that "There's a business case to be made to be a part of this solution."

Mark LaPalme, CEO and founder of the Isaiah House, an addiction-treatment center in Willisburg, told the group that placing recovering addicts in a strong community, such as a college or job, causes a 90 to 95 percent sober success rate beyond a year, Alvey reports.

Alvey writes that in the past, places of employment have been "toxic environments for people in recovery," but La Palme says, "Now we're not looking to fire people, now we're not looking to discipline people necessarily for disease and addiction. We're actually partnering to try and help them and help them get better."

The chamber also announced it would keep asking the Kentucky General Assembly to downgrade some drug possession charges from felonies to misdemeanors, Alex Acquisto reports for the Herald-Leader in a separate story.

“It’s not just a budgetary issue,” Ashli Watts, the chamber's senior vice president of public affairs, told Acquisto. “We have a workforce issue. We know we’re spending too much on corrections and we’re not seeing the [intended] outcomes. Our communities are not getting safer.”

“Treating it like an addiction and not necessarily a crime” is how the state should proceed, she said. “This is a population that needs second chances.”

Map from Kentucky Chamber of Commerce opioids report

In 2017, nearly 1,600 people in Kentucky died from an opioid-involved overdose. Since 2012, that rate has increased by 117% for heroin and by 564% for synthetic opioids, like fentanyl.

In Kentucky, anyone possessing either of these substances or other scheduled drugs is charged with a Class D felony, which can result in a one- to five-year prison sentence, even for a first offense. Not every Class D conviction results in a prison sentence; some are given the option of "rehabilitative diversion programs" to treat their substance use disorder in lieu of prison time, Acquisto notes.

Kentucky lawmakers have tried unsuccessfully to minimize drug-possession sentence through what is sometimes called a "peddler distinction" to exempt addicts. Last year, a chamber-backed bill to downgrade non-violent felony charges, including reducing drug-related Class D felonies to Class A misdemeanors, died in committee.

A 2017 state report commissioned by Gov. Matt Bevin to address the state's rising prison and jail population and recidivism rate found that between 2012 and 2016, there was a 38% growth in Class D felony admissions and a doubling of drug-possession admissions, Acquisto notes. At the end of 2016, the number of Class D inmates grew to 10,000, at an annual cost of roughly $18,400 each.

“What’s driving our prison population, to a great extent, is technical violations related to substance-use disorder,” such as a positive drug screen or missing a meeting with a parole officer, ODCP Executive Director Van Ingram told Acquisto. “We’re trying to increase the odds of that success.”

The chamber "is urging the state to adopt comprehensive policies that prioritizes rehabilitative options over penalties, particularly for first- or second-time offenders," Acquisto writes.

In addition to reclassifying drug-possession charges, the chamber wants more state support for substance-abuse treatment, more efforts to promote hiring people who are in recovery, and adding more harm-reduction programs such as syringe exchanges. The state has about 60 such programs, which are subject to local-government approval, which is often an obstacle.

The chamber represents 3,800 member businesses that employ over half of the state's workforce, according to its website. The chamber's Jacqueline Pitts detailed each topics on the lobby's news site, The Bottom Line.

Pitts wrote about personal stories of addiction, including that of former University of Kentucky basketball star Rex Chapman, who played 12 years in the NBA. He told the crowd that he became addicted to Oxycodone after an emergency surgery during his final season, and that he was "in love" with the drug after just two days of taking it. He said it took him several stints in treatment to get sober, but has been so for five years now.

Tick-borne disease in Ky. is relatively rare, but does occur; best defense against these tiny disease-carrying vectors is prevention

Top three tick posters from a contest held by the Kentucky Department of Public Health and Northern Kentucky Health Department, which attracted more than 700 entries (Click on it for a larger version.)

By Melissa Patrick
Kentucky Health News

Ticks and summertime go hand-in-glove, but that doesn't mean you can't enjoy outdoor summer activities; you just have to take extra precautions. Tick season in Kentucky runs through August.

“Spring and early summer are peak times for tick bites, which coincide with people venturing outdoors in the warmer weather,” Dr. Jeff D. Howard, commissioner of the state Department for Public Health, said in a news release. “It's important that people take preventive measures against tick bites and also check for ticks after visiting affected areas.”

Ticks are most likely to be hanging out in wooded areas; the boundaries between woods and fields; low-hanging tree limbs; under leaves, plants and ground cover; and around stone walls and woodpiles that are home to mice and other small mammals that carry ticks.

The health department recommends that Kentuckians remember four steps when it comes to protecting themselves from ticks: Protect; Check; Remove; and Watch.

Protect: To protect yourself from tick bites, avoid tick-prone areas, but if you are going to be in those areas use a tick repellent that has 20 percent DEET, picardin, IR3535 or lemon eucalyptus. Wear light-colored, long-sleeved shirts and pants tucked into socks. Use permethrin-based clothing sprays, unless you have cats, to which permethrin is toxic.

Check: After you've spent time outdoors, do a head-to-toe check for ticks using a hand-held or full-length mirror. Parents should check children. Common places to find ticks are behind the knees, around the waist, under arms, and on the neck and head. It is also important to check your gear and pets for ticks. If possible, change your clothes and shower after going outdoors. To kill ticks on dry clothes, put them in a dryer on high heat for 10 minutes. If clothes require washing, use hot water.

CDC illustration

Remove: Remove an embedded tick as soon as possible by grasping it as close to the skin as possible with tweezers and pulling straight out with gentle, even pressure. Do not jerk or twist the tick. Wash your hands with soap and water after the tick is removed. Apply an antiseptic to the bite site. Do not use alcohol, matches, liquid soap or petroleum jelly to remove a tick. Dispose of the tick by submerging it in alcohol, placing it in a sealed bag or container, wrapping it tightly in tape, or flushing it down the toilet. Never crush a tick with your fingers. Don't delay; remove a tick as soon as it is detected, because the longer it is attached, the higher the risk that it may transmit disease.

Watch: Watch for symptoms of tick-borne illness, including sudden fever and rash, severe headache, muscle or joint aches, nausea, vomiting, and diarrhea. Symptoms can arise within several weeks of removing a tick. Contact your health-care provider if symptoms occur.

Tick types and diseases in Kentucky

Overall, the incidences of tick-borne disease remains low in Kentucky, but that doesn't mean you shouldn't take precautions to protect yourself.

The lone star tick and the American dog tick are the most common ticks in Kentucky. And though bites from these ticks typically just cause local irritation and itching, a small percentage of them carry disease.

In particular, the adult female lone star tick, which has a white spot on its back and is about the size of a pencil eraser, can carry erlichiosis, a disease that can cause fever, headache, chills, muscle pain and in some cases a rash. Symptoms generally occur within one to two weeks of a bite. The first line of treatment is an antibiotic; if not treated properly, it can be fatal.

The CDC reports that Kentucky has one of the highest rates for cases of this disease, 9.7 per 1 million people. The lone star tick can also cause some people to become allergic to red meat.

The American dog tick is reddish-brown with mottled white markings on the back and is about the size of a pencil eraser. It can carry Rocky Mountain spotted fever, which usually begins with a sudden onset of fever and headache two to 14 days after being bitten by an infected tick.

Kentucky had 249 probable cases of Rocky Mountain spotted fever and one confirmed case in 2017, according to the state health department. Though rare, the bacterial disease can be deadly if not treated with the right antibiotics, with children under 10 making up most of the deaths, the CDC says.

Earlier this month, a 2-year-old Kentucky boy came down with a case of Rocky Mountain spotted fever that caused him to be unconscious for nearly a week, Lindsey Bever reports for The Washington Post. Kayla Oblisk told Bever that her son, Jackson, was bitten by a tick and they had just pulled it off and thrown it away without much worry. Within three days, he developed a dangerous high fever and developed a light pink rash all over his body. She said he was first diagnosed with a viral infection, but was eventually admitted to the hospital where he was diagnosed and treated for this rare but potentially fatal disease.

Both the American dog tick and the lone star tick can carry tularemia, a disease that infects animals and people and is often spread by rabbits. Symptoms of tularemia vary depending on how long the bacteria have been in the body and where the person contracted the disease. All forms of the disease are accompanied by fever. It can be life-threatening, but most infections can be treated successfully with antibiotics. In 2017, Kentucky had two cases of tularemia, according to the CDC.

A much smaller tick that is becoming more common in Kentucky is the blacklegged tick, also known as the deer tick. It carries Lyme disease, symptoms of which can range from mild to severe, including fever, headache, fatigue and a skin rash that looks like a bull's-eye, although not everyone gets the rash. This tick can also carry ehrilichiosis, which can weaken the immune system.

In 2017, Kentucky had six confirmed cases of Lyme disease and 14 probable cases, the CDC says.

Veterinarians in Kentucky now have access to a new program sponsored by the health department and the University of Kentucky that allows them to submit ticks for identification and testing. For more information about the program contact the program manager at tori.amburgey@ky.gov or the state public health veterinarian: kelly.giesbrecht@ky.gov.

A deeper dive

Elemental, a Medium publication for health-and-wellness journalism supported by science, has produced a multi-part special report about ticks called "Tickpocalypse" that explores in great detail the exploding tick population and the growing number of diseases that come with it.

The introduction to the series alarmingly refers to Lyme disease as a pandemic, a word that is only assigned to diseases that occur over a wide geographic area and affects an exceptionally high proportion of the population.

"It's estimated that 300,000 people contract Lyme each year in the U.S.," with victims found in all 50 states and Washington, D.C., it says. Further, it notes that Lyme is also on the rise in Europe, Africa and Asia.

Lyme disease is so bad that Mary Beth Pfeiffer, author of Lyme: The First Epidemic of Climate Change, calls for a "huge national and concerted international effort to bring it under control," Alex Bhattachari reports in one of the stories, "Lyme Disease Cases Are Exploding. And It's Only Going to Get Worse."

Bhattachari writes, "A public health crisis is hiding in plain sight, with tick-borne diseases creating millions of sick people at an economic cost running into the billions, and little has been done so far to mount a meaningful defense."

Other stories in the series are titled: "What It's Like to Have Lyme Disease Forever"; "Worrying About, Worrying About Lyme Disease"; "When Lyme Kills"; "What It's Like to be a Creepy-Crawler Field Researcher"; "Know Your Enemy: The Blacklegged Tick"; "When That Tick Bites"; "Lyme Prevention 101"; and "The Mouse Cure."

Study: Medicaid work rules caused coverage losses, no job gains in Arkansas; argument continues about what would happen in Ky.

By Melissa Patrick
Kentucky Health News

A study led by experts at Harvard University found that work requirements in Medicaid, like those proposed in Kentucky, resulted in thousands of people in Arkansas losing health coverage, with no evidence that they got jobs.

The study, published in the New England Journal of Medicine, brought predictable contrasting reactions from a health policy analyst and a Kentucky health official when asked if Kentucky can expect the the same results if the courts allow the rules.

"I don't see how Kentucky could expect any different outcome for its Medicaid program if it were allowed to go through," said Jason Dunn, policy analyst for Kentucky Voices for Health.

 Kristi Putnam, deputy secretary of the state Cabinet for Health and Family Services, disagreed. "We do not expect the same results," she said, adding that the study "does not tell the whole story."

Putnam manages the state's new Medicaid program, which wants the federal government to waive traditional Medicaid rules so the state can require, among other things, "community engagement" by most of the "able-bodied" individuals who gained coverage through the expansion of Medicaid to people who earn up to 138 percent of the federal poverty level. That means they would have to work, attend school or take job training 80 hours a month, or participate in drug treatment.

U.S. District Judge James Boasberg of Washington, D.C., has ruled twice against the waiver, as well as a similar one for Arkansas, after concluding that federal officials failed to show how work requirements would serve the objective of the 1965 Medicaid Act, which is to provide people with medical coverage. The administration of President Donald Trump has appealed the ruling.

Putnam said she doesn't think Kentucky would see the same results found in the Arkansas study,  largely because of the state's aggressive outreach campaign and its commitment to be flexible and proactive in its effort to improve the health of Kentuckians.

She said Kentucky''s roll-out period has been longer than the one in Arkansas, giving more preparation time; Kentucky is working with strategic partners who are committed to the program's success, like the Foundation for a Healthy Kentucky, the Kentucky Hospital Association, Kentucky Youth Advocates and all of the state's federally qualified health centers; employers and regional workforce development boards in the state are "excited and engaged" in the process; and the state continues to hold forums to inform stakeholders about the new requirements.

Communication is key

A big issue found in the Arkansas study was a lack of awareness and confusion about requirements that Medicaid beneficiaries report their work and community engagement activities. It found that one-third of the targeted adults had heard nothing about the policy, and that 44 percent were unsure whether it applied to them. Among those the state had told to report, only 49% were doing so regularly.

Putnam acknowledged that this is a "very legitimate concern," but said Kentucky is working hard to avoid the problem. She said field interviews with Medicaid beneficiaries in doctor's offices and health centers "found that a lot were not" aware of the rules. "And that kind of changed our approach in how we were communicating."

Putnam said the state plans to do more interviews, but has added more text messaging, increased its social-media presence, and is engaging with its strategic partners to get the information out, rather than relying on phone calls and mailed notices that are often not answered or read.

On the other side of the argument, Dunn said he expects the same outcomes as Arkansas because Kentucky has many of the same reporting hurdles, and that is what led to many in Arkansas to lose their coverage.  He noted that the study found that 95% of the people who lost their coverage in Arkansas shouldn't have because they were already working or would have qualified as exempt.

Putnam said that shouldn't be a problem here because Kentucky's technology is different. She said the state has gone to great lengths to assure that all reporting can be done from mobile devices, has worked to make sure the screens are easy to navigate and understand, and has designed the computer program to automatically exempt most people who qualify for an exemption.

Dunn disagreed. He said Kentucky Voices for Health has heard "a lot of complaints about the system" being difficult to sign up on, and difficult to use. The system is the same one people who are on the Supplemental Nutrition Assistance Program (formerly food stamps) use to report their work hours.

Dunn said recent reductions in Kentucky's SNAP rolls, due to failure to meet similar reporting requirements, indicate there would be similar drops in Medicaid coverage. "We've discontinued over 20,000 people through March of 2019, in about a one-year period," he said.

Putnam argued that the two programs offer different benefits and should not be compared. She said that because American health benefits are typically tied to hours worked, it is important to help Kentuckians learn how to work within that system. "The hope is that we can prepare people for the fact that this is part of our reality," she said.

Putnam added that Kentucky has the ability to be flexible and to react if it sees people dropping off the Medicaid rolls, which it will monitor "pretty much on a daily basis."

What's the objective?

Supporters of work and community engagement requirements have long argued that work requirements will spur employment and improve health.

In Arkansas, that didn't pan out. The researchers found no significant increase in employment, which fell from 42.4% to 38.9% among the targeted population. It also did not see a significant increase in the number of hours worked, or overall rates of job training or community service.

Putnam pointed to research that shows a connection between a person's overall economic well-being and their overall health well-being.

“We're more concerned with seeing improvements in health outcomes and people's well-being, but we believe that is very correlated to community engagement and improving your circumstances when you are able to," Putnam said.

Gov. Matt Bevin, a Republican who talked about the waiver in his 2015 campaign and is seeking re-election, has stated broader goals.

Bevin told Judy Woodruff on PBS News Hour last year that he would like to see all of the state's "able-bodied" people working or in some kind of community engagement, and asked, "Why should somebody have to go to work every day and pay taxes to provide something to someone who could do the same thing, but chooses not to? That's very un-American."

Dunn, of Kentucky Voices for Health, agreed that economic well-being is often tied to better health outcomes, but said it shouldn't be tied to any kind of eligibility.

“We like the idea of a service that provides linkages to educational opportunities and employment opportunities, we think as an overall effort in addressing social determinants of health that that is a good aspect of that – but not tying that kind of activity to eligibility. That is the part that is wrong," Dunn said. “I think what we'd like to see from this study is a better understanding that these kinds of policies do nothing but to serve to create new barriers to coverage. That they don't produce the results that people hypothesized and instead they lead to what a lot of researchers said was going to happen, and that is people lose their coverage."

Questions about the study

Putnam cautioned that the information gathered in the survey was self-reported and did not include any information about Arkansas' outreach efforts, nor any information from the Bureau of Labor Statistics, a federal agency that tracks employment. She added, "It does not tell the whole story of the individuals who are no longer getting Medicaid services."

Arkansas officials have said the study is not a "meaningful or thorough" evaluation, partly because it is based on less than a year's worth of data, Politico reports. They also said it did not address why most individuals who lost coverage did not re-enroll this year when they were again eligible.

Of the 18,000 who lost coverage, as of mid-May, roughly 4,300 had re-joined, Politico reports.

The study was led by the Harvard T.H. Chan School of Public Health. It looked at Arkansas' Medicaid work and community engagement requirements to see how insurance coverage and employment were affected. Arkansas was the first state to implement such requirements and prior to it being vacated by Judge Boasberg in March, the program resulted in 18,000 people losing coverage.

The study conducted telephone interviews with 30- to 49-year-olds, who were subject to the new requirements, compared with adults who were not subject to them. It also looked at outcomes for adults in three comparison states that have not implemented any work requirements: Kentucky, Louisiana and Texas (which, unlike the other two, has not expanded Medicaid).

In addition to finding a significant drop in insurance coverage among the 30- to 49-year-olds, from 70.5% to 63.7%, the researchers also found that the uninsured rate for this same group increased from 10.5% in 2016 to 14.5% in 2018, with smaller or no changes in the other groups.

The researchers found no significant increase in employment, which fell from 42.4% to 38.9% among the targeted population. It also did not see a significant increase in the number of hours worked, or overall rates of job training or community service.

The researchers concluded that the 18,000 people who fell off the Medicaid rolls in Arkansas after the work requirements were implemented neither secured jobs or other insurance coverage.

The most common reason (40.4%) for not reporting was a belief that they were not meeting the requirement, even though their responses indicated that they were meeting the requirement. Other reasons for not reporting were lack of internet access (32.3%) and confusion about reporting (17.8%).

"Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of persons lost coverage even though 95% of the target population appeared to meet the requirements or qualify for an exemption," the study report says.

The Trump administration has approved similar plans in nine states and seven more states have pending applications to add work requirements, according to the Kaiser Family Foundation.

New Hampshire's work requirements took effect this month. Jason Moon at New Hampshire Public Radio talked with health officials there and reports that "early signs are pointing to a bumpy road ahead." The issues described seem similar to those in Arkansas: confusion, lack of awareness, and difficulty with reporting requirements. This program is also being challenged in court.

The Commonwealth Fund estimates that if Medicaid work requirements are fully implemented in the nine states that have received federal approval, between 600,000 and 800,000 people could lose their coverage after 12 months. It is estimated that between 86,000 and 136,000 would lose coverage in Kentucky alone.

The state has estimated that after five years, Kentucky's Medicaid rolls would have 95,000 fewer people under the program than without it, in large measure for failure to meet reporting requirements.

Ky. children among least vaccinated for cancer causing human papillomavirus; state has highest rate of HPV-related cancers

Did you know there's a vaccine that can prevent certain types of cancer? Many Kentuckians don't know. As part of a statewide effort to educate them, a Bardstown woman told her story to a group in Louisville about being told at age 30 that she would have to have her uterus removed because she had cancer of the cervix, Darla Carter reports for Insider Louisville.

Jessica Saxe, a Kentucky mother who was diagnosed with
cervical cancer at age 30, promotes the HPV vaccine.
(Saxe provided this family photo to Insider Louisville.)

Jessica Saxe told those attending the Louisville event that her son, Charlie, was 9 months old at the time of her diagnosis. She recalled thinking, “I don’t know if I’m going to live to see him walk. … I don’t know if he will remember me,” her voice breaking. “That was the hardest part as a mother, knowing that I might not be able to be there for my son.”

Charlie is now 6. Carter reports that Saxe has since become an advocate for encouraging others to get vaccinated against the sexually transmitted human papillomavirus, often referred to as HPV.

She was speaking at an event sponsored by the American Cancer Society, along with the Kentucky Department for Public Health and others, to promote HPV vaccines, which are effective in preventing cervical cancer and genital warts. They will be traveling around the state over the next few months to promote the life-saving vaccine.

HPV is one of the most common sexually transmitted diseases, and Kentucky's children are among the least vaccinated for it. HPV can cause cancers in the cervix, vagina, vulva, penis, anus, rectum and the back of the tongue and throat. Among these cancers caused by HPV, more than 90 percent could be prevented by the vaccine, according to the Centers for Disease Control and Prevention.

“Kentucky has the highest cancer burden for HPV-related cancers in the nation, so morally we have to” take action, Elizabeth Holtsclaw, the state and primary-care systems manager for ACS, said at the event. She said the goal of their outreach is to increase vaccine rates by 8% in the next 12 months.

In 2017, about 38% of Kentucky youths 13 to 17 were up-to-date on HPV vaccinations, meaning they’d received the full series of doses, according to the CDC, which is providing funding for the meetings. That was up from 34% in 2016 but well below the U.S. rate of nearly 49%.

The HPV vaccine is recommended for girls and women starting around age 11 until 26. For boys, it’s recommended starting at age 13 until 21. Until 12, children receive two doses of the vaccine at least six months apart. Those 15 and older get three doses. The earlier the vaccine is given, the better the immune response. It is important to note that the vaccine is the only one known to prevent any form of cancer.

The vaccine is proven to be a safe and effective way to protect against the HPV virus, but can be a tricky sell to parents, Carter reports. “Part of it is nobody wants to admit that this 12-year-old is ever going to have sex, which is a fantasy,” Connie White, senior deputy commissioner of the health department, said at the event.

Another contributor to the state's low HPV vaccination rate is that health-care providers don't seem to be promoting it strongly enough, Carter reports. Studies show a "clear, same-day recommendation" from a physician to a parent is the most important factor in whether a child gets vaccinated or not. That also means doctors must carry the vaccine in their offices, but many don't. The vaccine is not on the list that must be administered to incoming students or sixth graders.

“Somehow, we are treating the HPV vaccine as an ‘other’,” Holtsclaw said at the event. “Whether it’s because it’s not mandatory, we don’t know. But other states are doing all right without a mandate. … The doctor needs to feel comfortable and confident making that strong recommendation.”

Another reason for getting the vaccine when young is that it is supposed to be given before exposure to HPV, so ideally, before the person becomes sexually active, according to the CDC. “It’s a cancer vaccine; it’s not a sex vaccine,” Saxe said.

Saxe, who recently had a second child with the help of a surrogate, told the group that it’s critical for cancer survivors to share their stories to help persuade more people to get their children vaccinated and prevent other women from getting cervical cancer, Carter reports.

“We can stop this, but we can’t do it alone,” she said. “We need the doctors and the nurses and the pharmacists. We need the people in public health. We need policymakers. We need you guys to stand with us on this. We need you to make this a priority.”

Bevin joins appeal of court ruling that blocked new association health plans; AG Beshear says they threaten health coverage

By Melissa Patrick
Kentucky Health News

Would association health plans, a type of insurance that makes it easier for small employers to band together, free of many of the requirements of the Patient Protection and Affordable Care Act, provide enough protections to consumers?

Business Management Daily graphic

Gov. Matt Bevin's health secretary says they would. Attorney General Andy Beshear, who is running against Bevin, says they wouldn't.

Bevin and officials from 15 other states, filed a court brief June 7 urging the U.S. Court of Appeals for the District of Columbia to reverse a lower court's decision against expanded access to association health plans.

The brief prompted a verbal tussle between Beshear, one of the original plaintiffs in the lawsuit, and Health Secretary Adam Meier, who released his statement from the governor's office, where he was deputy chief of staff, instead of the Cabinet for Health and Family Services, which he leads.

Beshear issued a statement saying, “I disagree with the governor’s new action because it threatens health care coverage for Kentuckians, including people with pre-existing health conditions. While Matt Bevin continues his work to strip vital coverage away from our families, I am fighting to make sure all Kentuckians get the health care they need and can afford it.”

In response, Meier called on Beshear to retract his "false and outrageous claim" and linked to official guidance from the U.S. Department of Labor that says association health plans "may not charge higher premiums or deny coverage to people because of pre-existing conditions."

“The Department of Labor has been very clear that association health plans cannot deny coverage to individuals based on pre-existing conditions,” Meier said. “To state otherwise is false and shows a complete lack of understanding of the intent of the Department of Labor rule, which is to provide workers and small businesses with greater access to affordable health insurance options. AHPs are a great way for sole proprietors and small businesses to have the same kind of health coverage that big corporations offer their employees.”

Technically, Meier is correct. But critics of the AHP rule say that while they recognize that the guidance says AHPs can't deny coverage based on pre-existing conditions, the rest of the policy is set up to allow them to easily do so by simply denying coverage for conditions they don't want to cover, such as not covering insulin for diabetics or not covering mental-health care.

The American Medical Association sides with Beshear on this issue. In a 2018 friend-of-the-court brief, the AMA laid out a list of concerns.

 "There is a significant risk that AHPs could disproportionately impact individuals with pre-existing conditions," the AMA said. "To be sure, on its face, the regulation states that it protects coverage of pre-existing conditions. But in reality, AHPs can easily evade that crucial legal requirement by using proxies for health status."

For example, AMA wrote that AHPs "can charge premiums based on factors that are not explicitly defined in terms of health or medical conditions, but that closely track those forbidden factors."

Further, it notes that the AHP rule allows them to charge different premiums based on age, gender, industry or geography. "But each of those seemingly neutral characteristics can be used to disguise differential treatment based on health status or one's likelihood of suffering from particular pre-existing conditions."

The AMA argued, "Denying patients coverage based on seemingly neutral characteristics that the insurance industry knows, in reality, are associated with higher medical costs or pre-existing conditions would leave patients with lower quality care, greater out-of-pocket expenses, and overall poorer health outcomes. Those consequences subvert the object and design of the ACA."

In addition to its concerns that AHPs will undermine the consumer protections in the ACA, the AMA said they would destabilize ACA exchanges by pulling healthy individuals out of ACA plans.

Citing examples, the AMA also noted that AHPs  have a "long history of fraud and abuse" and adds  that the AHP rule itself recognizes this when it says, "The Department anticipates that the increased flexibility afforded AHPs under this rule will introduce increased opportunities for mismanagement or abuse, in turn increasing oversight demands on the Department and state regulators."

What's it all about? 

President Donald Trump signed an executive order in 2017 to expand access to association health plans, stating that expanding access to such plans would "allow more small businesses to avoid many of the [Patient Protection and Affordable Care Act's] costly requirements."

In June of last year, the Department of Labor did just that, by expanding the types of groups that could ban together to offer coverage under an AHP.

The department also loosened association requirements so that more of them could be classified as large-employer coverage, which would exempt them from having to cover the 10 essential health benefits required by the ACA, like covering mental health or prescriptions. Nor, under the new rule, would they be required to pay the tax that large -group market insurers have to pay when they choose to not cover them. As previously noted,  association insurers can set premium rates based on age, gender, industry or geography.

In March 2019, the policy was struck down in federal court following a lawsuit filed by 11 attorneys general, including Kentucky's Beshear.

In his ruling, Judge John D. Bates, of the U.S. District Court for the District of Columbia, who was appointed by President George W. Bush, concluded that the labor department "unreasonably expands the definition of "employers" to include groups without any real commonality of interest" and that it had  misinterpreted the Employee Retirement Income Security Act's definition of an employer when it allowed working owners without employees to be covered by the AHPs. Bates added that the policy "was intended and designed to end run the requirements for the ACA."

This month, Bevin, along with 15 other states, filed a court brief urging the federal appeals court to reverse the district court's ruling. Bevin's involvement put Kentucky on both sides of the issue.

"By broadening the definition of a qualifying employer, more small businesses can take advantage of that purchasing leverage," says the brief. "Thus "a substantial number of uninsured people will enroll in AHPs because the Department [of Labor] expects the coverage will be more affordable than what would otherwise be available to them.""

AHPs in Kentucky?

The 2019 Kentucky General Assembly overwhelmingly passed House Bill 396 to update the Kentucky insurance code to adopt the Department of Labor's final rule and expansion of AHPs. Bevin signed it into law March 26.

Kentucky already has some association health plans that are fully insured and industry specific for employer groups, but has not approved any under the new policy, said Susan West, spokeswoman for the Public Protection Cabinet, which includes the Kentucky Department of Insurance.

West said in an email that the state was "on the cusp" of approving a fully insured AHP under the new rules that would have gone into effect June 27, but it has since been put on hold because of the federal court ruling and subsequent appeal. 

"Given the recent federal ruling and discussion among regulators at the recent [National Association of Insurance Commissioners] meeting, in which Kentucky participated, the DOI is waiting on the federal [Department of Labor] to determine their course of action and appellate options before moving forward with approving specific plans and registering associations," West said.

Rural hospitals continue to be at risk of closing; Medicare won't pay hospital rates for drastically scaled-down services

Rural hospital closures are a growing trend, and federal policies don't support a model that would include a scaled-back version of services. But that's what many rural hospitals need to do in order to ensure their future, Mary Meehan reports for Ohio Valley ReSource, a public-radio partnership that covers Kentucky, Ohio and West Virginia, especially their Appalachian areas.

“The reality is that many rural communities can’t really support a full-fledged hospital. They may need primary care and perhaps emergency department services, let’s say a primary care clinic attached to an emergency department," Ty Borders, director of the Rural and Underserved Health Research Center at the University of Kentucky, told Meehan.

But federal policy complicates that simplified model for care, Borders said: “Medicare won’t pay for that. Medicare will only pay for hospital or emergency department services that are in a hospital. And in most rural communities, that’s a critical-access hospital,” which limits its beds, services and patient stays in return for slightly larger federal reimbursements.

"Which are the hospitals that are closing," Meehan reports as she details the struggles and closures of several rural hospitals, starting with the Owen County Hospital in Owenton, which closed in 2016.

County Judge-Executive Casey Ellis told Meehan that over the years the hospital had operated for profit, not for profit, under a private owner and even under the support of a community foundation. It closed in 2016, but its emergency room continued operation under new management for 18 months.

“I have always seen it struggle,” Ellis said. “I grew up seeing it struggle.”

Such closures are part of a growing trend across the Ohio Valley and across the nation, Meehan notes. So far 107 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, and research shows the trend is accelerating. Four hospitals have closed in Kentucky since 2010, and several others are at risk of closing.

Meehan also writes about the Bell County seat of Pineville, where citizens ate "scrambling for options to save their hospital, even holding community prayer services."

"But troubles are of the earthly kind," she adds, noting that a declining population, old buildings and spending more on care than being reimbursed for it adds to the growing problem.

Meehan says research shows people are still getting the most critical care, but Ayla Ellison, managing editor of Becker's Hospital Review, told her that it can get more costly as caregivers become distant and must be transported farther to the nearest hospital, sometimes by helicopter.

Hosptials are often the largest employer in a county and are critical to its economy. Ellis told Meehan that about 50 people lost jobs when the Owen hospital closes, that it's hard to recruit jobs to a town with no hospital, and that as citizens age, they often move to communities nearer a hospital.

Ellis said the county has done what it can to help its 11,000 people across roughly 350 square miles, including developing 18 helicopter landing sites and by conducting a "huge campaign" on when and when not to call 911. The county has two ambulances to serve the entire county, Meehan reports.

“We can’t send a paramedic 20 minutes down the road to go see Miss Joe to change her bandage (and) talk about her medications” if that means risking a situation where no ambulance is available in a crisis, Dan Brenyo, the county's emergency-services administrator, told Meehan.

In the same week Meehan's story appeared, the rural hospital in Fentress County, Tennessee, 20 miles south of the Kentucky border, closed "following months of financial turmoil," Jacob E. Rosenbaum reports for the Fentress County Courier.

Jamestown Regional Medical Center, which had a staff of about 150, closed after it stopped receiving Medicare and Medicaid payments for new patients, Juan Buitrago reports for the Nashville Tennessean. County Executive Jimmy Johnson said the hospital missed a liability-insurance payment, worrying employees. CEO Michael Alexander told Buitrago that he hopes the hospital will be able to reopen. The next closest hospital, in Albany, Ky., is nearly 40 minutes away.

Rural hospitals are at a greater risk of closing in states that did not expand Medicaid under the Patient Protection and Affordable Care Act. Tennessee is one of the 14 states that have not done so; Kentucky did. According to the North Carolina research program, 12 rural hospitals have closed in Tennessee since 2010, three in 2019. A separate report shows that Tennessee has 15 rural hospitals at high risk of financial distress, and Kentucky has eight. The researchers' list is not public.

UPDATE, July 1: ABC News reports on the hospital closures in Celina and Jamestown, Tenn.