Medicaid isn't off the budget-cutting table, but seems resilient because it covers so many and is vital for rural hospitals

Protesters in 2017 (Photo by Drew Angerer, Getty Images)

Now that President Biden and Republicans agree they won't cut Medicare and Social Security, the federal-state Medicaid program will be on the table as Republicans try to get concessions for raising the national debt ceiling. But "Medicaid is politically better positioned to weather the storm than ever," Politico's Joanne Kenen reports.

While the House Republican platform for midterm elections was vague about cuts, "and even more vague on health policy, the conservative Republican Study Group’s budget blueprint for the current fiscal year would have restructured Medicaid entirely and cut $3.6 trillion over a decade compared to the current spending trajectory — but there’s no way that Democrats (or even some more establishment Republicans) would accept that," Kenen writes.

Medicaid has "a much stronger constituency" these days because it covers many more people, 90 million, including 1.7 million in Kentucky, more than a third of the state's population.

The program is "the largest payer of nursing-home care in the U.S, and it’s a lifeline for disabled kids and their families, both very politically sympathetic populations," Kenen reports, citing Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. “Medicaid now is touching the majority of families in the country,” Joan Alker, executive director of the Center for Children and Families at Georgetown University in Washington, D.C., told Kenen.

"As if all that wasn’t enough, Medicaid keeps safety net hospitals afloat," Kenen notes." And those hospitals, which treat a large share of poor people in both rural and urban settings, are in an even more precarious financial position than usual after the pandemic. . . . Tom Miller, a health expert at the center-right American Enterprise Institute who has written extensively on what he sees as more realistic conservative approaches to improving Medicaid, including broader use of federally-approved waivers for states, expects conservative Republicans to try again this year — and again overreach and fail."

Rural Ky. needs more community health workers and medical-school residents, legislators and UK hospital executive say

Charles Aull of the Kentucky Chamber of Commerce, upper left, moderated the webinar.

By Al Cross
Kentucky Health News

Improving health care and health in rural Kentucky will take more people in the health-care workforce, specifically at the top and bottom of the pay scale, two key legislators and one of the state's top hospital administrators said Tuesday, June 8.

Kentucky needs more health-care workers overall, because it may lose some to the pandemic, Mark Birdwhistell, vice president for health services administration at the University of Kentucky and chief of staff for UK HealthCare, said during a Kentucky Chamber of Commerce webinar on rural-urban health disparities.

"Coming out of Covid . . . many of our clinical workforce are fatigued, and they're second-guessing: 'Is this the career path that I want to go on?' They've been in combat for a year and a half now," Birdwhistell said.

State Rep. Kim Moser, a Republican from Taylor Mill in Northern Kentucky, agreed. "Burnout is real," she said, noting that her husband is a pulmonologist who has treated Covid patients.

The need for more community health workers, who are not health-care providers but can educate people about care and help them get it, came up as Birdwhistell, a former state health secretary, discussed the 2014 expansion of the federal-state Medicaid program for lower-income Kentuckians.

"Just because you've got coverage doesn't mean you've got access" to the health care you need, Birdwhistell said, because "Many providers don't take Medicaid." He and Baptist Health Louisville President Larry Gray said health insurance tends to cost more in rural areas due to lack of competition, so people buy policies with high co-payments and deductibles.

The expansion of Medicaid made clearer how the "social determinants of health" leave rural areas with lower health status, Birdwhistell said. It's twice as likely for someone in an urban area to finish high school or college as someone in a rural area, he said, so health literacy is lower in rural areas. And that extends to health insurance, he said, giving one example: "Deductible. That's hard to explain in English."

Moser, a retired nurse who chairs the state House Health and Family Services Committee, said expanding the limited government and commercial-insurance reimbursement for community health workers' services would help. "That is one policy that we're looking at possibly expanding," she said.

Birdwhistell said that would be "very, very cost-effective," because "In a lot of communities, people don't know how to access care, and they show up in the emergency room. And that is probably the worst place for anybody to show up with a high fever, strep throat, whatever. They don't get a continuum of care. . . . They will listen to somebody that they grew up with, somebody that they go to church with, somebody that they see on the soccer field with their kids."

Service area of Kentucky Homeplace

Eastern Kentucky already has the third largest concentration of community health workers in the nation, trailing only Alaska and northwest Mississippi, according to the Bureau of Labor Statistics.

That is likely due to Kentucky Homeplace, a 27-year-old program of UK's Center for Excellence in Rural Health in Hazard. It says it helps people in the region with "lifestyle choices, environmental factors, inadequate health insurance and general lack of understanding of the health-care system."

Nationally, CHW pay averages $46,000 a year, but in Kentucky the average is $37,320.

The webinar discussion also addressed the need for more doctors in rural Kentucky.

Birdwhistell said a major obstacle to getting more physicians in rural areas of the state are the limits on federally funded residency slots at the UK and University of Louisville medical schools. "Flipping that switch could pretty instantly change the number of professionals we have coming out," he said.

Republican Sen. Ralph Alvarado of Winchester, a physician, agreed, saying that residents tend to set up practices within 80 miles of where they do their residency. Moser also endorsed the idea.

Alvarado, chair of the Senate Health and Welfare Committee, noted that some rural areas have a shortage of health-care providers, which he blamed on state laws that make malpractice insurance expensive.

Gray said the shortage is especially bad in Eastern Kentucky, which needs providers who are willing to come to the region with "a sense of mission and vocation." But even with enough providers, transportation to get some patients to them is still an obstacle in some areas, he said. The expansion of telehealth has helped, he said, but some areas still lack internet access that is fast enough for it.

And even with telehealth, a shortage of specialists blocks care. For example, Kentucky has only 59 child psychiatrists, and half of them "are cash-only, don't take insurance," Alvarado said.

The panel started out by discussing some of the state's poor health statistics. Alvarado said the use of tobacco is heavier in rural areas, leading to all sorts of health issues, and obesity is more common, causing "more negative outcomes."

The news isn't all bad, he said, noting how Kentucky has raised its screening for colon cancer from 47th to 19th in the nation. "That's going to rub off on our death rates . . . in 10 years," he said. "There is some hope." But he also noted that screening rates in Eastern Kentucky remain relatively low.

Kentucky will run out of its KCHIP money in about six months; meanwhile Congress inches toward funding the program

By Melissa Patrick
Kentucky Health News

As Congress works to fund the Children's Health Insurance Program days after the Sept. 30 deadline for reauthorization passed, Kentucky officials are confident their funding will be renewed before the federal money runs out.

"Without funding reauthorization on the federal level, we have enough money to maintain CHIP services for about six months," Doug Hogan, spokesman for the Cabinet for Health and Family Services, said in an e-mail. "We fully expect federal funding to be renewed."

An estimated 11 states are expected to run out of federal CHIP money by the end of the year, and 21 more by March 2018, according to a study by the Kaiser Family Foundation. A separate foundation report shows that the federal budget for CHIP was about $14 billion in 2016 and Kentucky's federal share was around $243 million.

CHIP and its funding vary by state with some states sharing the program's expense with the federal government. Hogan said Kentucky's program, called KCHIP, is largely funded by federal dollars.

Kentucky's program covers uninsured children younger than 19 who live in families with income at or below 218 percent of the federal poverty level, $53,628 for a family of four). The program serves about 83,000 children in Kentucky and almost 9 million nationwide.

The historically bipartisan program was initially passed in 1997, renewed in 2015 and was set to be renewed on Sept. 30 -- but Congress failed to act, instead spending its time on a second attempt to repeal and replace Obamacare which fell short a few days before the Sept. 30 deadline.

Both the Senate and House have passed bills out of committee to refund CHIP, but the Senate bill doesn't specify how the program will be paid for, and the House bill includes funding offsets that involves taking money from an Obamacare prevention fund and charging seniors who make more than $500,000 a year higher Medicare premiums. These offsets were a source of contention for Democrats, and the bill passed on a party-line vote, reports the Washington Examiner.

Since, Republicans on the House committee have agreed to return to negotiations with Democrats in hopes of reaching a bipartisan agreement, Jessie Hellmann reported Oct. 10th for The Hill.

However, the chairman of the committee, Greg Walden (R-Ore.) warned in a statement that if they can't reach a deal by the end of this week, the marked up bill will be taken up by the House when they return from their recess Oct. 23.

Dr. Terry Brooks, executive director of Kentucky Youth Advocates, said in an Oct. 2 statement that while he understands the "partisan toxicity and ambiguity" around Obamacare, "kids should not pay the price for partisan politics" and called for a bipartisian effort to extend the program's funding.

“Though leaders in Washington may assert that states should shoulder this vital coverage for children, the federal government cannot expect an already strapped state budget to absorb the costs of the program,” he said. “And Washington cannot turn its back to the families counting on CHIP to ensure better health outcomes for their sons and daughters."

He added, “Senate Majority Leader Mitch McConnell has a track record of standing tall for kids. We need him to protect CHIP – and our kids – from being a casualty in the never-ending Washington D.C. health care debate. Congress must extend CHIP funding with declarative and immediate action!”

Kentucky Voices for Health sent a letter Oct. 4 to leadership of the aforementioned House and Senate committees that had more than 100 "sign-ons" urging Congress to "quickly pass a clean extension of CHIP and continue the bipartisan commitment to this successful program." The letter noted that KCHIP had contributed to the state's uninsured rate of less than 7 percent, with the rate of uninsured children falling to 3.2 percent.

No final congressional action is expected until late October at the earliest, when the House gets back from its recess.

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

Kentucky Health News

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

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

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

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

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

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

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

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

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

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

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

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

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

Sen. Rand Paul (Getty Images)

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

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

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

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

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

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

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

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

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

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

Yarmuth says McConnell won't let a health bill get a Senate vote for fear it would backfire on Republican senators

Majority Leader Mitch McConnell says the U.S. Senate is working on its own health-care bill, but Kentucky's only Democrat in Congress said Friday that McConnell won't bring the bill to a vote in order to protect his fellow Republicans from retribution by voters, Ronnie Ellis reports for CNHI News Service.

Yarmuth (WDRB image)

“I’m convinced that Mitch McConnell will not allow anything to get out of the Senate because he doesn’t want any one of his members to have to take a vote on health care,” Rep. John Yarmuth of Louisville told Together Frankfort, a civic-engagement group. “At least a half-dozen could be vulnerable if they have to cast a tough vote on health care.”

Republicans have 52 Senate seats to Democrats’ 48, including two independents who vote with Democrats, Ellis notes. In the 2018 elections, only eight seats now held by Republicans are up, putting Democrats on the defensive. "But Democrats are feeling increasingly optimistic about their 2018 prospects – especially in the House, where they need to pick up 24 seats to gain control — in the aftermath of constituent unhappiness over the House healthcare vote and Trump’s rocky first three months in office," Ellis reports.

McConnell spokesman Robert Steurer "didn’t directly address Yarmuth’s comments, instead pointing to a floor speech McConnell gave earlier this past Wednesday in which he said the ACA continues to fail “'the American people and keeps getting worse'," Ellis reports. "He went on to say Democrats have indicated a willingness to work with Republicans on 'common-sense reforms' and said he welcomes Democrats’ input."

"With control of the White House and both chambers of Congress, Republicans are scrambling to make good on their promises while trying to preserve popular provisions" of the Patient Protection and Affordable Care Act, Ellis writes. "After a failed attempt earlier this year, House Republicans narrowly passed the American Health Care Act, which has prompted angry protests at congressional town halls. Critics say the measure will cut Medicaid by $880 billion over 10 years, weaken or eliminate the prohibition on denial of coverage due to pre-existing conditions, and ultimately cost 24 million people health-care coverage."

McConnell has named 13 Republicans to write a bill that Republicans "hope to pass on a simple majority vote through what is known as the reconciliation process," Ellis notes. "Such votes can only be taken on legislation which pertains to the budget and the federal deficit and the Senate parliamentarian must rule on whether legislation qualifies for such a vote. Otherwise, Republicans would need 60 votes to avoid a Democratic filibuster."

Yarmuth said Republicans have realized “they have no place to go on health care,” and that the only acceptable alternative to "Obamacare' is a single-payer system. “I’m convinced that within 10 years there’s going to be a major push for Medicare for everybody and it’s going to come from corporate America,” he said.

UK gets $11.2 million, five-year grant to study links between cancer and obesity, two of Kentucky's biggest health problems

Kentucky leads the nation in some forms of cancer, and is among the leaders in obesity. Is there a connection? The federal government is giving the University of Kentucky $11.2 million to explore the connection over the next five years, through a new Center for Cancer and Metabolism.

"The center will focus on the underlying mechanisms that link dysfunctional metabolism to cancer. Recent studies have shown that the mitochondria of cells can influence how aggressive a cancer becomes," Linda Blackford reports for the Lexington Herald-Leader. "According to the U.S. Centers for Disease Control and Prevention, Kentucky ranks first in the nation in incidences of colorectal cancer in men and women, and seventh in deaths. People who are obese are about 30 percent more likely to develop that kind of cancer."

Lisa Cassis, UK's vice president for research, said the grant from the National Institutes of Health will also “enable the university to foster the development of the next generation of scientists who will lead our efforts in translating basic research findings into promising new therapies.”

Cassis said, “Research is at the heart of any progress we hope to make in bridging health gaps in the commonwealth.” She recently crticized the proposed cut of 20 percent to NIH funding in President Trump’s federal budget, saying the move would reduce UK’s federal funding from $92.4 million in 2016 to $75 million, meaning a loss of 219 jobs.

“It is not just reductions in NIH funding that are important; it is the types of research that would be reduced if these reductions were realized,” she wrote. “This is especially important, as health conditions that devastate our citizens exist at higher rates in Kentucky than the rest of the U.S. More Kentuckians die of cancer, and Kentucky ranks in the top 10 in heart attacks, drug deaths, strokes, diabetes, cardiovascular deaths and obesity.”

"UK officials said U.S. Senate Majority Leader Mitch McConnell contacted the NIH in support of the grant," Blackford reports. "In March, the Kentucky Republican said he didn’t support Trump’s proposed cuts to medical research funding."

American Health Care Act would have major impact on Ky. by phasing out Medicaid expansion, changing private insurance

By Danielle Ray and Al Cross

Kentucky Health News

The acronyms may be similar, but the American Health Care Act, Republicans' replacement for the Patient Protection and Affordable Care Act, would overthrow some core tenets of "Obamacare" and have major impacts on Kentucky.

The ACA and the AHCA are mainly about the individual health-insurance market, where about 7 percent of Americans get coverage, but in Kentucky, the law's biggest impact is the expansion of the federal-state Medicaid program. About 440,000 Kentuckians get free health care through the expansion, while only 82,000 are enrolled in Obamacare plans subsidized by federal tax credits.

Medicaid expansion would be phased out

Under the ACA, Kentucky and 30 other states expanded Medicaid to people with incomes up to 138 percent of the federal poverty level, now $16,394 for an individual or $33,534 for a family of four.
Under the ACA, this would be phased out over time, and open-ended federal funding for the states would be replaced with block grants based on a certain amount per Medicaid member.

The block grants would grow more slowly than actual costs, so states would have to pay progressively more or reduce expenses, explains Harris Meyer of Modern Healthcare. The bill would increase the percentage of people who are uninsured and raise uncompensated-care costs for hospitals and other health-care providers, Modern Healthcare reports.

Providers and patient-advocacy groups worry that the block-grant structure would drastically cut funding over time, forcing states to cut eligibility, benefits and provider payments. The American Hospital Association, the Catholic Health Association, America's Essential Hospitals and the Association for Community-Affiliated Plans have all come out in opposition to the bill in its current form, citing concerns about Medicaid, Meyers reports.

Because Medicaid has considerable turnover, as people gain or lose eligibility or choose to enroll or not, the number of people on the expansion would decline over time. The Congressional Budget Office has yet to estimate how many people would lose coverage or how much the bill would cost.

The organizations that oppose the proposed changes to Medicaid have urged lawmakers to wait for the CBO to score the bill's impact on spending and coverage levels. An early analysis from S&P Global Ratings estimates that four million to six million people now enrolled in Medicaid would lose coverage under the AHCA.

Drug treatment: The bill would eliminate the existing requirement that Medicaid cover basic mental-health and addiction services in states that expanded it, letting the decide whether to include those benefits. This point is of particular concern in states like Kentucky that have been hit hard by the opioid crisis and thus have a greater population in need of addiction treatment services.

"With Kentucky's current opioid epidemic, we can't afford to go back to the days when people had no way of getting substance use treatment or behavioral health services," Dr. Sheila Schuster, board chair of Kentucky Voices for Health, said in a news release on Wednesday. "Over time, Medicaid cuts would give us far fewer options to meet the needs of Kentuckians."

(Image from Twitter; click on it for a larger version)

Politics: The Republican bill would stop expansion enrollment on Jan. 1, 2020, but conservatives have objected to the delay, and "White House officials are beginning to urge House GOP leadership to include an earlier sunset of the Medicaid expansion," reports Jeremy Diamond of CNN. But Greg Sargent of The Washington Post writes, "This would mean that the fallout hits right amid the 2018 midterm elections, something that could not only impact the congressional and Senate races, but also the hugely consequential 2018 gubernatorial contests, in which repeal of the Medicaid expansion could create major complications."

An earlier phase-out of Medicaid expansion would also complicate prospects for the bill in the Senate, where several Republicans want to protect it for their states and GOP leaders can't afford to lose more than two GOP votes. (Kentucky Sen. Rand Paul is expected to be one; he called the bill "Obamacare Lite" in a tweet on Tuesday, and expressed disapproval of its ACA holdovers.) However, the Senate could take a more moderate stance once it gets the bill and pressure the House to accept that version, NBC reports.

How money would flow: Under the AHCA's per-capita grant model, states would receive a flat amount of federal dollars for each of five Medicaid beneficiary groups: the elderly, blind and disabled, children, adult expansion beneficiaries and adult non-expansion beneficiaries. States would then decide whom to cover, which benefits to offer and how much to pay providers.

The bill would use fiscal year 2016 as a baseline for each state's per-capita spending for each of the five beneficiary groups. Those baseline figures would then be trended forward to fiscal year 2019. In 2020, the Department of Health and Human Services would use those figures to compare a state's spending target with its actual per-capita spending. The target would be calculated using the medical component of the Consumer Price Index, which lags behind actual Medicaid per-capita costs, Meyer notes.

"If a state's per-capita cost growth exceeded the target, the federal government would take back its excess payments by reducing its contributions in each quarter of the following year," Meyer reports.

Private insurance would change

One of the biggest changes to private insurance would be how policies are subsidized. The existing program uses advance tax credits to help offset out-of-pocket costs. The tax credits are based on age, income and local insurance prices. (Learn more about how tax credits are calculated here.) The AHCA would offer tax credits based only on age, and with a different structure.

Graphic from The Economist

Lower-income people would get lesser tax credits than they do now, and credits would be available to higher-income people who don't get them now. Tax credits for small businesses would be eliminated.

Individuals with modified adjusted gross incomes under $75,000, or married couples with MAGI under $150,000, would get the same, fixed amounts for their age groups. People above those thresholds would have their tax credit would be reduced by 10 percent of the income above the threshold.

Tax credits would start at $2,000 a year for people under age 30, increasing in $500 increments per decade in age, up to $4,000 a year for people 60 and older. The credits would be limited to $14,000 per family, FactCheck.org writers explained in USA Today. The new structure would take effect in 2020, with modifications in 2018 and 2019 to give more to younger people and less to older people.

Rural areas are more vulnerable than urban areas to cuts in subsidies because the existing program takes local insurance costs into account and the AHCA does not. Counties in western, southern and southeastern Kentucky are particularly vulnerable to such scenarios. Find out how your county would be affected with this interactive county-by-county map from the nonpartisan Kaiser Family Foundation.

Critics say this structure hurts low-income Americans and benefits the wealthy. "Kentucky has gained more from the Affordable Care Act . . . than any other state, and we have more to lose from its repeal," Jason Bailey of the liberal-leaning Kentucky Center for Economic Policy said in a news release. "The new House proposal is a plan to give tax breaks to the wealthy paid for by dramatically reducing the number of people with health coverage."

The AHCA would allows for a wider range in insurance pricing; insurers could charge older individuals up to five times as much as younger people, and states could change that ratio, FactCheck notes. Under current law, the ratio is three-to-one. Thus, young people could see lower premiums while older ones could see higher premiums.

Other provisions: In addition to tax credits, current law offers cost-sharing subsidies to reduce copayments and other out-of-pocket costs for people earning between 100 percent and 250 percent of the federal poverty level. The AHCA would eliminate those subsidies in 2020 but create a Patient and State Stability Fund with $100 billion over nine years that could be used for various purposes, including mitigating out-of-pocket costs.

The AHCA would increase the amount that could be put into tax-exempt health savings accounts, now $3,400 for individuals and $6,750 for families, to $6,550 and $13,100, respectively. The bill also aims to allow people to use HSA money for over-the-counter drugs. Current law allows HSA money to be used for an over-the-counter drug only if the patient first received a prescription for it.

The bill would eliminate the requirement that almost all Americans have health-insurance coverage, but would encourage people to remain insured by letting insurance companies charge a penalty for not having continuous coverage. Insurers could charge 30 percent higher premiums for one year, regardless of health status, to people entering the individual market who had a lapse of coverage of 63 days or more during the previous 12 months.

An early analysis from S&P estimates that 6 million to 10 million fewer people will have health-insurance coverage as a result of the bill. Read a detailed summary of the AHCA here.

Senate takes first step toward repealing Obamacare; Rand Paul, worried about deficit and debt, is only Republican to vote no

Paul, McConnell (Washington Post photo)

Citing concerns about the federal budget deficit and the national debt, Rand Paul of Kentucky was the only Republican senator to vote against a non-binding resolution that paves the way for repeal of the Patient Protection and Affordable Care Act.

Passage of the resolution early Thursday morning was led by Kentucky's other senator, Majority Leader Mitch McConnell, who said, "We must act quickly to bring relief to the American people."

Paul said in a press release, “As a physician, I cannot wait to repeal Obamacare and replace it with a health care system that relies on freedom to provide quality, comprehensive, and affordable care. But putting nearly $10 trillion more in debt on the American people’s backs through a budget that never balances is not the way to get there. It is the exact opposite of the change Republicans promised, and I cannot support it, even as a placeholder.”

The House may vote on the measure Friday, but "some Republicans there have misgivings about setting the repeal effort in motion without a better idea of the replacement plan," Andrew Taylor reports for The Associated Press.

President-elect Donald Trump said Wednesday that "Obamacare" would be replaced at virtually the same time it is repealed. "That promise, however, will be almost impossible to achieve in the complicated web of Congress, where GOP leaders must navigate complex Senate rules, united Democratic opposition and substantive policy disagreements among Republicans," Taylor writes. "Republicans are not close to agreement among themselves on what any 'Obamacare' replacement would look like."

Taylor offers background: "The 2010 law extended health insurance to some 20 million Americans, prevented insurers from denying coverage for pre-existing conditions and steered billions of dollars to states for the Medicaid health program for the poor. Republicans fought the effort tooth and nail and voter opposition to Obamacare helped carry the party to impressive wins in 2010, 2014, and last year."

Thursday's vote "set up special budget rules that will allow the repeal vote to take place with a simple majority in the 100-member Senate, instead of the 60 votes required to move most legislation," Taylor writes. "That means Republicans, who control 52 seats, can push through repeal legislation without Democratic cooperation. They're also discussing whether there are some elements of a replacement bill that could get through at the same time with a simple majority. But for many elements of a new health care law, Republicans are likely to need 60 votes and Democratic support, and at this point the two parties aren't even talking. . . . Increasing numbers of Republicans have expressed anxiety over obliterating the law without a replacement to show voters."

Paul has been working with members of the conservative House Freedom Caucus, who want to know details or put some elements of replacement in the repeal bill. "Some GOP senators have discussed a phase-in of three years or longer to give lawmakers more time to replace Obama's overhaul and make sure people now covered by that law can adjust to a new program," Taylor notes. "Some more moderate House Republicans were unhappy, too, including Rep. Tom MacArthur, R-N.J., a leader of GOP centrists in the House Tuesday Group. He said he would oppose the budget because there was too little information about the replacement, including whether people receiving expanded Medicaid coverage or health care subsidies under the existing law would be protected.

"We're loading a gun here," MacArthur said. "I want to know where it's pointed before we start the process."

Sen. Rand Paul offers plan to repeal most of Obamacare; would remove requirement to cover pre-existing conditions

U.S. Sen. Rand Paul of Kentucky "is gathering support among Republican lawmakers for an ACA replacement plan designed to make health insurance less expensive by lifting many of the health law’s key requirements," including coverage of pre-existing conditions, which President-elect Donald Trump wants to keep, Alex Ruoff reports for the Bureau of National Affairs, a Washington newsletter service.

Kentucky was one of the states helped most by the law's requirement to cover pre-existing conditions, according to a recent report by the Kaiser Family Foundation. It said 33 percent of non-elderly Kentuckians, about 880,000 people, had pre-existing conditions that would have allowed companies to refuse to insure them.

Paul's plan would also remove the requirement that all Americans have health insurance, which was designed to balance insurance companies' coverage of pre-existing conditions. "The plan, similar to those floated by House Republicans recently, would expand use of tax-advantaged health savings accounts to help people afford the cost of health services," Ruoff reports.

Sen. Rand Paul

“What we need to do is make available inexpensive insurance so healthy people will buy it,” Paul said.

Paul has been leading a push against the plan of Kentucky's other senator, Majority Leader Mitch McConnell, and other Republican leaders to repeal budget-related elements of Obamacare with a budget resolution, which is not subject to a filibuster and the 60-vote requirement to end it, and pass replacements elements later.

"Paul said he still supports using the budget reconciliation process to repeal the health law, but acknowledged a replacement plan would need to be passed outside reconciliation and require support from some Democrats," Ruoff writes. There are 52 Republican senators.

"Paul’s replacement plan tracks along the plans other conservatives have introduced in recent weeks, with some key differences. He’s among those calling for the most aggressive repeal and replace timeline as well," Ruoff reports. "Paul’s plan would lift nearly all the ACA’s major provisions and mandates, including the mandate that certain employers give their employees health insurance coverage, and would roll back requirements that define what benefits insurers must provide enrollees, known as essential health benefits."

Paul, citing deficit, is among small but potentially pivotal group of GOP senators who want Obamacare replaced when repealed

This story was updated Monday, Jan. 9.

Kentuckian Rand Paul is among a small but growing and potentially pivotal group of Republican senators who say the Patient Protection and Affordable Care Act should be replaced at the same time it is repealed. And now President-elect Donald Trump appears to be with them.

“He called after seeing an interview that I had done [talking about] that we should vote on Obamacare replacement at the same time,” Paul said told Burgess Everett of Politico on Monday. “He said he was in complete agreement with that.”

"With Trump going out of his way to bless the Kentucky senator’s approach, Paul’s week-long campaign to hold a vote on replacing Obamacare alongside a simultaneous repeal measure has seemingly upended the GOP’s long-sought plans for a cathartic and immediate vote to gut the health care law, Everett reports. "As news broke that Trump backed Paul's play, several other Senate Republicans were also beginning calls for a new strategy — threatening the trajectory of the party’s rush to repeal the law."

Paul says repealing parts of the law in a budget resolution, the only way around the Senate's 60-vote requirement for most major votes, would add too much to the federal budget deficit and the national debt.

"He’s putting together an initial proposal containing the GOP’s best ideas and will ship them this afternoon to Trump’s administration after getting buy-in from the president-elect," Everett reports. "He’s putting together an initial proposal containing the GOP’s best ideas and will ship them this afternoon to Trump’s administration after getting buy-in from the president-elect."

Paul was the only Republican to join Democrats on a procedural vote Wednesday that allowed the Senate to consider the resolution, but "at least five other Senate Republicans have signaled they are uneasy over repealing the law without having settled on its replacement," Kristina Peterson and Stephanie Armour of The Wall Street Journal. "GOP leaders have said they plan to develop replacement legislation this year, which would go into effect after a transition period of two to three years."

Senate Majority Leader Mitch McConnell of Kentucky, who discussed Obamacare with Trump Monday in New York, can afford only two dissenters in his 52-member Republican caucus, because 50 votes are needed to pass a budget resolution, with a tie-breaking vote from Mike Pence after he becomes vice president and president of the Senate. Until Jan. 20, 51 votes are needed.

Aware of that, "Sens. Ted Cruz of Texas, Mike Lee of Utah and Marco Rubio of Florida wrote Tuesday in a joint letter to GOP Senate leaders that while they understood the budget was “primarily a mechanism to advance [the health law’s] repeal,” the Senate should still abstain from any budget devices that they oppose," the Journal reported.

Paul said on MSNBC's "Morning Joe," “Everybody is hot and heavy to vote on this budget because they want to repeal Obamacare. But the budget they’re going to introduce will add $8.8 trillion to the debt over the next 10 years. So I told them look, I’m not going to vote for a budget that never balances.”

Paul later said he would support a stand-alone repeal measure, and Arkansas Sen. Tom Cotton expressed views similar to Paul's. But on the moderate side of the Republican caucus, Sen. Susan Collins of Maine "wants Republicans to both repeal and replace the law at the same time," at least with what she calls "a detailed framework," and both Tennessee senators have taken similar stands.

The latest was Bob Corker, who said Friday that it "would be best for our country to go ahead and replace it with something that works and repeal at the same time." He called immediate repeal "a flawed concept."

Corker "noted that President-elect Donald Trump voiced support during the campaign for moving the two together and told '60 Minutes' in November that he backed repealing and replacing ObamaCare simultaneously," Jordain Carney reports for The Hill. Corker said, "I think the president-elect's position is the right position."

Paul tweeted Friday that he had just spoken with Trump, "and he fully supports my plan to replace Obamacare the same day we repeal it." But Trump adviser Kellyanne Conway said on CNN's "State of the Union" said only that "He is committed to replacing Obamacare with something that actually is affordable and accessible and allows you to buy health insurance over state lines and allows people to have health savings accounts."

Asked about Paul and Obamacare Sunday on CBS's "Face the Nation," McConnell said he hadn't seen a replacement plan from Paul but said Congress would pass one "rapidly." he declined to be more specific.

Democrats in Congress lose key round in bid for immediate anti-addiction funds; threaten filibuster that could kill the bill

Deaths from prescription overdose hit a record high in 2014

By Danielle Ray
Kentucky Health News

Democrats are threatening to filibuster the proposed Comprehensive Addiction and Recovery Act after a Democratic-led effort to secure nearly $1 billion in anti-opioid addiction funds failed in a congressional conference committee Wednesday.

The amendments by Rep. Frank Pallone of New Jersey and Sen. Patty Murray of Washington were defeated in straight party-line votes. Republicans argue there is no need for additional spending because anti-addiction funds have already been proposed as part of the House Appropriations Committee's fiscal 2017 budget.

GOP committee leaders released a draft of that bill on Wednesday, which allocates $581 million to the Substance Abuse and Mental Health Services Administration to combat opioid and heroin abuse.

Democrats contend the drug epidemic is so urgent that more money is needed immediately. Nearly 29,000 people died from opioid overdose in the U.S. in 2014, including almost 1,100 Kentuckians.

“We have an opportunity and the clear responsibility to take life-saving action on this issue today,” Murray said in a news release. “We have a choice between preventing more of the deaths we've all heard too much about and allowing the status quo to continue.”

Democrats sent a letter to conference committee chair Rep. Fred Upton (R-Mich.) on Tuesday threatening to oppose the CARA bill if "significant funding" is not included in the conference report. If Democrats keep their pledge, the bill could face defeat in the Senate.

Though the measure passed in conference and has enough Republican support to push a final version through the House, a partisan split in the Senate—which would require a Republican supermajority of 60 votes to overcome a filibuster—could effectively stall the legislation.

Republicans refuse to fund the provisions in the bill without offsets from other programs that would render it budget-neutral. The Congressional Budget Office estimates that the bill would cost about $1.2 billion over five years, but those numbers do not take into account possible "downstream" savings these programs could create, like decreased prison populations and fewer addicts relying on other government programs.

Without Democratic-backed funding, CARA puts just $181 million in new money toward prevention, treatment and recovery.

Senate Majority Leader Mitch McConnell of Kentucky said Democrats should support the report despite their failed attempt at additional funding.

"The conference report the Senate will soon consider can make a difference for the American people," he said in a news release. "It’s the product of years of hard work, and it’s very similar to the CARA bill that already passed the Senate with no Democrat opposition."

The debate comes one day after the Obama administration unveiled a list of actions to fight the opioid epidemic. It includes expanding the number of patients certified doctors can treat with buprenorphine from 100 to 275. The U.S. Department of Health and Human Services also wants to eliminate potential financial incentives for doctors who prescribe opioids out of fear that patients will give them low marks in patient-experience surveys if they have pain after procedures.

The House is expected to cast a final vote on CARA on Friday and the Senate early next week.

Bacteria that can't be treated by any antibiotic now in U.S.; Kentucky ranks first in one type of antibiotic-resistant infection

A colorized scanning  of E.Coli
Credit: CDC/Jancie Haney Carr

For the first time, researchers have found a person in the United States carrying bacteria that can't be treated by "last resort" antibiotics.

The antibiotic-resistant bacteria found in the 49-year-old Pennsylvania woman's urine was from a strain of E.coli bacteria that is resistant to an antibiotic called colistin, a last-resort drug with serious side effects that is used only when other antibiotics don't work.

For example, colistin is used to treat the superbug carbapenem-resistant Enterobacteriaceae, commonly called CRE, which health officials call a "nightmare bacteria."

Nearly half of patients who become infected with CRE die from it, Lena H. Sun and Brady Dennis report for The Washington Post.

The Pennsylvania woman was able to be treated with other antibiotics, but the discovery of the colistin-resistant strain has placed health officials on alert.

Health officials say it's not time to panic, but there is great concern that this colistin-resistance gene could spread to other bacteria that are also antibiotic-resistant creating many more bacteria strains that are untreatable, reports the Post.

The colistin-resistant strain was first found in pigs, raw pork and a few people in China in November. It has also been found in Europe.

“It basically shows us that the end of the road isn’t very far away for antibiotics — that we may be in a situation where we have patients in our intensive care units, or patients getting urinary-tract infections for which we do not have antibiotics,” CDC Director Tom Frieden told the Post.

Separate research found that the same colistin-resistant strain was found in a sample from one pig intestine in the United States. Colistin is widely used in Chinese livestock, but is not used in the United States, though plenty other antibiotics are, Tom Philpott reports for Mother Jones.

"Around 80 percent of the antibiotics sold in the United States go to livestock farms, and of that, 60 percent are considered crucial to human medicine," Philpott writes. Farmers mostly use antibiotics to help their livestock grow faster.

Yohei Doi, an infectious-disease doctor at the University of Pittsburgh, told the Post that he thought the widespread use of the antibiotic in Chinese livestock is likely what has led to the bacteria evolving and gaining resistance to the drug, and then leaping from livestock to humans through food.

Dr. Kevin Kavanagh, a retired physician and chairman of HealthWatch USA, said he isn't convinced that the U.S. pig was infected by livestock from China. He noted that colistin is commonly used to treat CRE, cystic fibrosis and that a form of colistin can be found in many over-the-counter topical antibiotics.

"It's probably more likely that the pig in the U.S. obtained this from the farmer's medicine cabinet than from another pig in China," Kavanagh said.

Experts in infectious diseases have called for action to curb the overuse of antibiotics in livestock worldwide. They have also warned that if these antibiotic-resistant bacteria continue to spread, treatment options could be severely limited.

Kavanagh  recognized the importance of research around the overuse of antibiotics in livestock but said that he thought more emphasis should be placed on the human side of healthcare related to antibiotic-resistance bacteria than the agriculture side of it.

 "The foremost emphasis should be placed on controlling antibiotic usage, controlling the spread of these organisms and surveillance of these organisms. ... We don't really know how many infections exist because we have a fragmented reporting system, but you know how many cows there are in each county," he said.

The federal Centers for Disease Control and Prevention estimates that at least 2 million people are infected with antibiotic-resistant bacteria each year, and 23,000 die.

Kentucky ranked first in MRSA cases, July 2014 - June 2015.

HealthWatchUSA

Kentucky has one of the highest prescribing rates of antibiotics in the nation and also leads the nation in another antibiotic resistant infection called MRSA (methicillin-resistant staphylococcus areus).

"Overuse of antibiotics has got to stop," says Kavanagh said. "The use of antibiotics needs to be curtailed to only when it is necessary. ... Every time you take an antibiotic you remove your good bacteria and run a real risk of activating a superbug in your body which can cause you extreme harm and even death. You should only take antibiotics when you have to take them."

Pharmaceutical companies have stepped away from developing new antibiotics because they aren't very profitable. But William Schaffner, medical director of the National Foundation for Infectious Diseases, told WebMD, "The Infectious Diseases Society of America has been working with Congress and with industry to create incentives for the pharmaceutical industry to reopen its antibiotic research laboratories."

In addition, "Late last year, as part of a broader budget deal, Congress agreed to give hundreds of millions of dollars to the federal agencies engaged in the battle against antibiotic-resistant bacteria," reports the Post.

Lifting of ban on federal funding for needle-exchange programs has the potential to help Kentucky fight disease, but not yet

By Melissa Patrick
Kentucky Health News

U.S. Rep. Hal Rogers and Senate Majority Leader Mitch McConnell, Kentucky's top Republicans in Congress, played a key role in lifting a longstanding ban on federal funding for needle-exchange programs in the budget deal enacted in December.

Rep. Hal Rogers, Sen. Mitch McConnell
(Getty Images photo by Win McNamee)

McConnell and Rogers said they acted to help thwart the spread of disease from increased intravenous drug use in Kentucky, but the change has had no immediate effect because no federal money in the state is allocated for needle exchanges.

"We don't have a pot of federal money that we can re-direct to needle exchange programs," said Scott Lockard, Clark County's public health director and president of the Kentucky Health Departments Association.

Most departments' "federal funding is tied to specific programs with specific guidelines and we don't have the flexibility to reallocate any of that to needle exchange," Lockard said. "On down the road it may be beneficial, but there is nothing immediate that is going to help health departments fund their programs."

Kentucky's needle-exchange programs are part of the anti-heroin bill the General Assembly passed in 2015. It is intended to prevent the spread of disease and steer drug users toward treatment. The law requires local government approval and funding, requirements that have discouraged needle exchanges. Fewer than 10 localities have them, and the Scott County Fiscal Court is the latest to delay action.

Kentucky suffers more than 1,000 drug overdose deaths each year and leads the nation in cases of hepatitis C. Dirty needles are also blamed for the spread of HIV, which leads to AIDS.

Rogers spokeswoman Danielle Smoot confirmed that there is no new federal money at this time to support needle exchange programs.

"What I understand is that the federal dollars that go through the state to the counties can be used for these programs," Smoot said. "The whole purpose of this is that it just relieves the restrictions on the money."

But it's not that simple, because the federal dollars allocated for public health come with restrictions.

Deputy Health Commissioner Kraig Humbaugh reaffirmed what Lockard said, explaining that the state Department of Public Health applies for federal grant awards, but these grants are always earmarked for a specific purpose and there is little leeway on how the grants can be used.

However, Humbaugh said, "It has the potential, certainly, to help communities decide to operate a syringe exchange program. ... We will keep our eyes open for potential opportunities for grant awards that might be out there ... or it could be that opportunities may come up for direct funding for the local health departments."

McConnell spokesman Robert Steurer said in an email that the intent of the law may help open up some federal dollars for needle exchanges. He said the U.S. Department of Health and Human Services "is developing guidelines to implement the flexibility provided in the omnibus language, and we have to wait for those guidelines before determining how Kentucky may benefit. The intent of the language makes clear that federal funds should flow to certain areas based on the approval of needle exchange programs at the state and local level, the rate or risk of an outbreak of Hep C and/or HIV, among other factors."

Three more Kentucky counties, two of them rural, recently approved needle exchanges, making six counties with them

By Melissa Patrick
Kentucky Health News

Jessamine, Carter and Elliott counties are the latest Kentucky counties to approve needle exchange programs, joining Fayette (Lexington), Jefferson (Louisville) and Pendleton counties.

The approval of exchanges in Carter and Elliott counties, in northeastern Kentucky, creates a major rural beachhead in a state where officials have said rural officials will be slow to adopt the strategy of preventing HIV, hepatitis and other diseases transmitted by illict drug users.

The major obstacle is a widespread belief that needle exchanges enable drug users, despite studies that say otherwise. That has created another big hurdle, lack of federal funding. However, Congress removed that obstacle last month at the behest of two Kentuckians: Senate Majority Leader Mitch McConnell and U.S. Rep. Hal Rogers, chair of the House Appropriations Committee.

The two Republicans had opposed federal funding for needle exchanges, but recently led the charge to get Congress to lift a ban that was enacted in 1988, lifted in 2009 and reinstated in 2011 The latest change was included in the omnibus spending package passed in December. The measure still doesn't allow federal funds to be spent on the syringes themselves, but it can be spent on relayed costs such as staff, transportation, counseling, treatment referral and outreach.

Not only does the lifting of this ban potentially bring much needed dollars into Kentucky to help pay for the exchanges, but the support of two top Republicans and the federal government could go a long way in convincing local governments to support needle exchanges in the state, Laura Ungar reports for The Courier-Journal..

Kentucky's needle-exchange program is part of the landmark heroin bill the General Assembly passed in 2015. It is intended to prevent the spread of disease and steer drug users toward treatment. Kentucky leads the nation in hepatitis C and suffers more than 1,000 drug overdose deaths each year.

However, the law requires local-government approval for needle exchanges, which has proven to be a challenge in many counties, even Northern Kentucky an urbanized area that has been hit hardest by heroin.

Jessamine County

Jessamine County Public Health Director Randy Gooch said about 20 county health boards have approved needle exchanges, but most have been thwarted by city or county governments, reports Rosalind Essig of The Jessamine Journal.

Gooch said he hoped Jessamine County's action would encourage other communities to start talking about needle exchanges and hoped that to do likewise.

“The more that smaller communities — maybe like Jessamine and Pendleton County — are able to engage the community and create these programs, the stronger that we become, from a public health perspective,” Gooch told Essig.

Jessamine County is the most recent county to get approval for a needle exchange. Its Fiscal Court voted 4-2 in favor of it Jan. 19. The Nicholasville City Commission, with a 4-1 vote, and the Jessamine County Board of Health had already given approval, Essig reports.

The county and city officials struggled with such concerns cost, efficacy, mandated counseling and whether the program enables drug use.

“I am excited, and it's been a long road," Gooch said after the final vote. "It's a difficult thing, I know, for elected officials and for the community, as well, because most people are very skeptical, because they think it's enabling the users.” Gooch told Essig that addicts will inject drugs regardless of whether they have clean or dirty needles.

As for the cost, Gooch said in the meeting that the health department would involve community partners and existing staff to do the work so that it would not incur a high cost, stating that he did not foresee a tax increase to pay for it. He noted that one of their partners is St. Joseph Jessamine, which will dispose of the needles for free. He estimated the program could grow to about 200 participants, putting the cost of the one-time-use-only syringes at about $4,300 a year.

Jessamine's program will operate one day a week at the local health department during normal business hours, and will provide a separate entrance for the participants. After initially providing addicts with clean syringes based on their level of drug use, the program will then require future needle exchanges to be one-for-one.

The Jessamine Journal recently published the first of a series of stories about heroin and its impact on the local community. The Woodford Sun has published a similar series, but its health board has not acted. Both communities are largely suburbs of Lexington.

Carter and Elliott counties

The Little Sandy District Health Department, which serves Carter and Elliott counties, has received a $3,900 grant from the Kentucky Agency for Substance Abuse Policy to help fund a needle exchange program through June. 30, at which point the district will cease to exist because Carter County is quitting it, Joe Lewis reports for the Journal-Times in Grayson. "The needle exchange program would presumably fall under the direction of the new Carter County Health Department," Lewis writes.

Carter County will have to re-evaluate whether it can maintain the program, Trena Greene, nursing supervisor for the health department, told Kentucky Health News.

Greene said the final protocol for the program was submitted Jan. 13 at the board meeting and awaits approval. She said it will be a one-for-one needle exchange, held on set days and times. It will be conducted at two offsite locations, one in Grayson and the other in Olive Hill.

Hepatitis C cases are being reported to our health department at "two or three or four a week," Greene said. It is "just phenomenal."

"When they come for the needle exchange, we can offer rapid hepatitis C and HIV testing," Greene said. "And of course, we will offer them resources and counseling at the time we make the connection," with the goal of getting the users into a treatment program.

Greene said Carter and Elliott counties and the Carter County towns of Grayson and Olive Hill gave approval for the exchange some time ago, and the state grant allowed it to move forward.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Bevin and Medicaid expansion featured on HBO's 'Last Week Tonight' comedy show; illustrated philosophical divide

Oliver discusses Bevin on "Last Week Tonight."

The future of Kentucky's Medicaid expansion was a topic for liberal comedian John Oliver on HBO's "Last Week Tonight" Sunday night. It was short on facts, but did help illustrate a philosophical divide between ruling Democrats and the Republican nominee for governor.

Oliver focused on elections in three states: Mississippi, where Republican Gov. Phil Bryant faces no opposition; Virginia, where only legislative elections are on the ballot; and mainly on Kentucky, the only state where a governor's race could decide the future of a Medicaid expansion.

"Perhaps the most striking election this year is in Kentucky," Oliver said, noting Democratic Gov. Steve Beshear's acceptance of federal money to expand Medicaid. "Only an idiot would try to undo that. Which brings me to gubernatorial candidate Matt Bevin." Oliver played video of a recent debate in which Bevin denied saying he wanted to kick people off Medicaid, and then an earlier one in which he says he would immediately end the expansion upon taking office.

He did not give Bevin's current position: that he would apply for a federal waiver to revise the program to shift some costs to some recipients. However, he suggested that Bevin might put some Kentuckians in "what's known as the Medicaid gap," created by the Supreme Court when it "struck down the part of the law that enabled the federal government to force states to expand Medicaid." The millions in the gap, mainly in the 20 states that did not expand Medicaid, make too much money to qualify for the program but not enough to afford private insurance, even with Obamacare subsidies.

Noting that Bevin got a state grant in Connecticut to help reopen his family's bell factory after a fire, Oliver said, "The real irony here is that Bevin did not have insurance to cover the fire because he said no company would insure the buildings 'for a price that made sense.' That's right. Because the cost of insurance was too high, he needed to turn to the government for help."

A Kentucky law, passed by a Democratic legislature and governor in 1966, makes it state policy to take full advantage of federal funding for Medicaid. Beshear cited the law in announcing the expansion. The federal government is paying the full cost of the expansion through 2016; in 2017, states will have to pay 5 percent, rising in annual steps to the reform law's limit of 10 percent in 2020.

"I cannot think of anything I would not buy if I had to pay only 10 percent of the price," Oliver said. He cited four Republican governors who have expanded Medicaid: Jan Brewer of Arizona, Chris Christie of New Jersey, Mike Pence of Indiana (in a way Bevin has cited a possible example of his own plan) and John Kasich of Ohio, who is running for president and told an interviewer, "That's not Obamacare, that's Medicaid."

" ... a big dump truck full of money ... "

Oliver said, "All Kasich did was see a big dump truck full of money back into his driveway and not say 'stop'."

Bevin doesn't see it that way. Last week, when an interviewer reminded him that another piece of Obamacare was paid for by federal money, he challenged the questioner and said, "That's our money."

Here's the Medicaid segment of Oliver's show, which runs 14 minutes:

8 of 23 health insurance cooperatives closing, more likely to follow; they blame Republicans; Republicans blame Obamacare

By Melissa Patrick
Kentucky Health News

One-third of the 23 health insurance cooperatives created under the Patient Protection and Affordable Care Act are closing, with others likely to follow. Republicans say this is yet another failure of "Obamacare," but health co-ops say Republicans denied them the money they needed to stay open. Others say the health co-op model is not sustainable.

Co-ops in Kentucky, Colorado, Iowa, Louisiana, New York, Nevada, Tennessee and Oregon have announced they are closing, and Insurance Business America reports that it expects this number to increase, with reports "suggesting that federal officials have a list of 11 Obamacare health insurance co-ops on the verge of failure," but the officials won't name them.

The co-ops were created under federal health reform as non-profit, consumer-governed health plans, with $2.4 billion in low-interest loans. They were designed to give for-profit companies more competition and to hold down rates. The eight failed co-ops received nearly $900 million, with the Kentucky Health Cooperative receiving over $146 million.

Several of the co-ops, including Kentucky's and Colorado's, fully expected to overcome their losses, but couldn't sustain the hit of not getting these expected subsidies. Kentucky's co-op lost $50 million last year but had reduced its losses to $4 million by the end of June.

"We were on track to reverse direction and begin operating in the black, and we expected this to come about in 2016," Glenn Jennings, who took over as CEO of the Kentucky co-op in June after Janie Miller resigned, said in a news release.

Joe Smith, chair of the cooperative's board of directors, said in an interview, "If we had of been allowed to book the outstanding risk corridor as a receivable, we would have been in compliance with the risk requirements."

These closures will impact almost 500,000 policyholders, according to The Wall Street Journal. That which includes 51,000 Kentuckians, who will have to seek alternative insurance for 2016. Open enrollment begins Nov. 1.

"Republicans say it’s doubtful if the federal government will ever recoup the millions of dollars in seed money the startups received," Stephanie Armour reports for the Journal. She quotes Sen. Cory Gardner, R-Colo., as saying the money "will likely never be repaid. . . . The years since Obamacare’s passage have been marked by crisis after crisis in health care, and it’s far past time for a new plan."

Republican gubernatorial candidate Matt Bevin said taxpayers will be responsible for paying for the losses of the Kentucky co-op, in a statement calling for an Obamacare debate with his Democratic opponent Jack Conway, who declined.

Smith, the co-op board chair, said he didn't know what the future held related to this debt, saying it will likely be a "complicated resolution."

"We plan to meet our obligation to members and the providers with the monies that we have available from now until the end of the year," he said. "What happens after that is . . . who knows?"

Many of the failed co-ops, including Kentucky's, blame their demise on a reduction in expected federal payments through the "risk corridor" program, which is meant to subsidize insurers who take on high-risk customers. These reductions are a result of restrictions that Republicans added to the omnibus spending bill last December that barred the administration from using other federal funds to make up the shortfalls. The Kentucky co-op was hoping for $77 million in risk-corridor money and got $9.7 million.

"Quite frankly, if you go back to the sequestrations, which the Republicans brought into place, it is the cause of all of this," Smith said. "Somebody really needs to sit down and look at what Congress did over the last couple three years that has caused this to happen to most of the co-ops. They set out to destroy the Affordable Care Act and this is a piece that they found they could do."

Insurers had asked for about $2.87 billion in payments based on their 2014 results, but the Centers for Medicare and Medicaid Services said that there was only $362 million available to make those payments, which came from collections from other insurers that had performed well, Armour reports.

Kentucky Health Cooperative sold 75 percent of the policies bought through the state health-insurance exchange and attributed some of their troubles to the fact that they attracted too many unhealthy people and thus had to pay out much more than expected in claims.

U.S. Senate Majority Leader Mitch McConnell says the idea that Republicans should take any of the blame "couldn't be further from the truth," and said Kentucky's co-op, "like the others, collapsed under its own weight." McConnell wrote in rebuttal to a political column by Al Cross in The Courier-Journal and other newspapers that said the GOP helped cause the failure of the co-ops.

On Oct. 21, McConnell said on the Senate floor, "The administration knew beforehand that this plan was not viable and that tens of thousands of people could lose their coverage. They chose to cling fast to a disastrous left-wing experiment with our health-care system over choosing stability and affordable coverage for the many people caught up in Obamacare and these failed health-care co-ops."

Smith, asked if the Kentucky co-op has any hope of getting additional risk-corridor money, said, "I am not sure, quite frankly. From our perspective, they owe us another 60 million dollars. I'm just not sure if it is going to come or not."

Colorado HealthOP said in a statement that the decision to close its co-op was "irresponsible and premature" and that it was “well on its way” to repaying its loans early. The co-op reported a net loss of $23 million last year.

The New York Times reports that some experts have said these new co-ops have been "hobbled" from the beginning because the "federal loans granted to co-ops to get established are typically far below the capital needed to weather the uncertainty of the first years and be able to attract enough members to be successful." It also notes that the regulations attached to the loans make it hard to attract outside money.

In an opinion piece for Forbes, Tim Worstall, who writes that he is "not a great fan of Obamacare," says that the failure of the health co-operatives created under the ACA "isn't really a failure of Obamacare as such. Rather, it's a failure of the cooperative model" in an industry that has large capital requirements, noting that the co-ops that have succeeded typically started small and have grown over time.

Armour also notes that co-ops struggle because they tend to attract younger, healthier people and, "many were required under the risk adjustment formula to pay fees to help cover the sicker patients who signed up with established carriers."

Because of these failures, dozens of surviving health co-ops, smaller insurers and new benefit providers are forming a coalition, Armour reports, writing,"The coalition wants changes to a federal formula known as risk adjustment, which takes money from plans with healthier and younger enrollees and gives it to plans with older and sicker customers to spread out financial pressures on insurers. The health co-ops and smaller insurers say the formula, along with another health law program that aims to offset insurers’ financial losses, is putting them out of business."

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.