Ky. nursing-home industry says Biden administration's rule mandating staffing levels for homes is 'impossible' to meet

Centers for Disease Control and Prevention photo

By Melissa Patrick
Kentucky Health News

A new law that sets minimum staffing requirements for federally funded long-term care facilities will require many of them to hire more nurses and nurse aides. It has been met with pushback from the nursing-home industry. 

Morgan Jemtrud, director of communications for the Kentucky Association of Health Care Facilities and the Kentucky Center for Assisted Living, told Kentucky Health News in an email that the staffing mandate is not attainable for several reasons, including the health-care workforce shortage. 

"The staffing mandate is impossible. CMS estimates it will cost around $300,000 per building (AHCA estimates more), but there is no funding to support the implementation of the rule," said Jemtrud. "Also, the required staff are simply not available. RNs are in demand across all health -care sectors, and no pipeline is being built to produce the number of RNs this rule requires." 

Jemtrud was referring to an analysis from the American Health Care Association, a nursing-home lobby, that says meeting the mandate would require nursing homes to hire more than 100,000 more nurses and nurse aides at an annual cost of $6.8 billion. The analysis also says 94% of nursing homes were not meeting at least one of the proposed staffing requirements.

New staffing requirements

The "Nursing Home Minimum Staffing Rule" requires all nursing homes that receive Medicare or Medicaid payments to provide 3.48 hours of direct nursing care per resident per day, including a defined number for registered nurses (0.55 per resident per day) and nurse aides (2.45 hours per resident per day). 

"This means a facility with 100 residents would need at least two or three RNs and at least 10 or 11 nurse aides as well as two additional nurse staff (which could be registered nurses, licensed professional nurses, or nurse aides) per shift to meet the minimum staffing standards," says a White House fact sheet about the rule.

It will also require facilities to have an RN onsite 24 hours a day, seven days a week, to provide skilled nursing care. 

The new staffing requirements will be phased in over three years, except at rural facilities, which will get up to five years. The law allows for some "limited, temporary exemptions" for facilities in areas with workforce shortages that demonstrate a good faith effort to hire the required staff. 

Within two years, most homes must provide an average of at least 3.48 hours of daily care per resident. About 6 in 10 nursing homes are already operating at that level, according to a Kaiser Family Foundation analysis. But the analysis says only 19% meet the defined number of hours required for RNs (.55)  and nurse aides (2.45) that is required under the full implementation of the law.  

“When facilities are understaffed, residents may go without basic necessities like baths, trips to the bathroom, and meals – and it is less safe when residents have a medical emergency,” said the fact sheet,  noting that it will also “ensure that workers aren’t stretched too thin by having inadequate staff on site.”

Brice Mitchell, spokesperson for the state Cabinet for Health and Family Services, told Kentucky Health News in an email that the administration is reviewing the federal rule and its impact. 

"Medicaid funds 70% of all long-term care in the state and there is ongoing work to expand a nurse career ladder to help increase recruitment," Mitchell said. "At this time, we are unable to determine the number of Kentucky nursing homes that don’t meet the new federal rules." 

Pushback on the new mandate

Denise Wells, executive director of the Nursing Home Ombudsman Agency of the Bluegrass, said her group was "very pleased" with the 24-hour RN requirement, but didn't think the minimum hours per resident per day went far enough.

She said  the 24/7 RN requirement is important because the acuity level of patients has increased over the years, meaning patients need more assistance with their activities of daily living than ever before. And, she said, "Medical emergencies don't just happen for eight hours of the day; they can happen 24 hours a day." 

Wells said they were disappointed in the hours per resident per day only being 3.48 because research shows that the minimum care that an average resident needs is 4.1 hours per day.

"And that is simply to avoid negative health outcomes," she said. "It's not to live their best lives, it's not to have the greatest quality of life, it's just to have that minimum care provided." 

Wells called the new staffing rules a "good first step." 

"We are trying to make sure that the message is that this is not the ceiling; that it's a floor," said Wells. "It's the absolute minimum, but facilities should be staffing higher than this. . . . Nursing homes are required to staff to sufficient levels to meet resident needs, and so if they have residents that their care plan indicates that they need more than the 3.48 hours per day, then the facility needs to staff to meet that need." 

Jemtrud with KAHCF and KCAL was asked about the financial impact of the rule. She said Kentucky nursing homes are already financially strained and there are no funds to help meet the new requirements. 

"Before this rule, 79.9% of Kentucky facilities are in distress or at risk of financial distress using the Altman Z-score," Jentrud said, citing a formula used to determine a company's risk of bankruptcy.

"CMS estimates the total cost of the final rule at about $4.3 billion per year, but AHCA continues to estimate the cost above $6 billion per year," she said. "There are no funds from Medicare, Medicaid, or other payers to increase payment rates to providers for any of the rule requirements." 

Wells, asked how facilities can address the health-care workforce shortage, said her group prefers to call it a "job quality crisis" caused by low pay, poor conditions and little support.  She pointed to reports from the National Consumer Voice for Quality Long-Term Care that have showed how nursing homes hide profits, and saif there is not enough transparency in how Medicaid and Medicare dollars are used these facilities. 

KFF Health News also points to researchers who are "skeptical that all nursing homes are as broke as the industry claims or as their books show. A study published in March by the National Bureau of Economic Research estimated that 63% of profits were secretly siphoned to owners through inflated rents and other fees paid to other companies owned by the nursing homes’ investors."

In a lengthy statement from the American Hospital Association, Stacey Hughes, AHA executive vice president, said, in part, "CMS’ one-size-fits-all minimum staffing rule for nursing homes creates more problems than it solves and could jeopardize access to all types of care across the continuum, especially in rural and underserved communities that may not have the workforce levels to support these requirements."

The American Health Care Association issued a statement in opposition of the mandate and said the industry will keep pressing Congress to overturn the regulation. 

“While it may be well intentioned, the federal staffing mandate is an unreasonable standard that only threatens to shut down more nursing homes, displace hundreds of thousands of residents, and restrict seniors’ access to care,” Mark Parkinson, CEO of the AHCA, said in a statement. “Issuing a final rule that demands hundreds of thousands of additional caregivers when there’s a nationwide shortfall of nurses just creates an impossible task for providers. This unfunded mandate doesn’t magically solve the nursing crisis.”

The mandate also implements stronger transparency measures to ensure nursing home residents and their families know when a nursing home is using an exemption, according to the fact sheet.  

Guthrie expresses concern

Jemtrud said industry associations will "continue to reach out to Congress where there’s been bipartisan support for helpful legislation." 

"Providers have been hosting legislators for visits within their facilities to share firsthand the challenges they’re facing," she wrote. "Also, the AHCA/NCAL Congressional Briefing scheduled June 3-4 will allow members to discuss their concerns directly with members of Congress on Capitol Hill." 

On Tuesday, U.S. House Republicans at a House Energy and Commerce health subcommittee voiced their concerns about the new staffing mandate. 

The subcmmittee chair, Republican Rep. Brett Guthrie of Kentucky's Second District, said he was "extremely concerned" about the mandate along with the 80/20 rule which requires agencies that provide home- and community-based services to spend 80% of their Medicaid payments on compensation for workers who directly provide care. 

Guthrie said both rules "threaten access to long term care services for Medicaid beneficiaries by setting arbitrary staffing and pay standards. . . . This approach simply won't work." He added later, "These rules come at a time where we have seen more than 500 nursing home facilities close since the start of the pandemic and where we have 150,000 fewer long-term care workers than we did before 2020."

Rep. Guthrie's bipartisan bill to increase access to breakthrough therapies for people on Medicaid advances out of committee

Rep. Brett Guthrie addresses the House Energy
and Commerce Committee May 24. (Screenshot) 

U.S. Rep. Brett Guthrie's bipartisan bill to help Medicaid patients access breakthrough therapies, including gene therapies, to treat and cure rare diseases was approved by the House Energy and Commerce Committee on Wednesday, May 24.

The bill would allow access to innovative treatments and cures by enabling states to voluntarily enter into value-based purchasing (VBP) agreements for drugs, which ties the cost of treatments to patients' clinical outcomes. 

The bill, H.R. 2666, has been dubbed the Medicaid VBPs for Patients Act, or MVP Act. It was one of 19 pieces of legislation considered by committee on May 24, many of them aimed at increasing transparency and competition in the health-care industry.

Guthrie, a Republican from Bowling Green who represents the Second Congressional District, chairs the committee's Health Subcommittee, which approved the bill May 17. He issued a statement saying:

“The Medicaid VBPs for Patients Act would help get life-saving treatments to the most vulnerable patients across the country. With the flexibility this legislation provides, states can make high-cost therapies and cures for rare diseases available without raising taxes or cutting other state programs. Value-based payments ensure states are not on the hook for paying a drug manufacturer for a high-cost treatment if it is not effective and can even save states money in the long-term in caring for a patient.”

Guthrie added, “I will continue pressing for this legislation that better aligns incentives in health care and helps people have a better life.”

The other sponsors of the bill are Democratic Reps Anna Eshoo of California and John Auchincloss of Massachusetts and Republican Reps. Mariannette Miller-Meeks of Iowa and Dr. John Joyce of Pennsylvania.

Two Kentucky hospitals, in Lexington and Prestonsburg, each lose $2.4 million in very different lawsuits over 'patient dumping'

Baptist Health Lexington (Photo for The Courier Journal by Jack Weaver)

Highlands ARH Medical Center, Prestonsburg

Two Kentucky hospitals have recently lost lawsuits that charged them with “patient dumping,” generally defined as discharging patients who are uninsured or unable to pay – or refusing to admit them in the first place, reports Andrew Wolfson of the Louisville Courier Journal.

The judgments were virtually the same, but the cases were very different.

On Aug. 31, a Floyd County jury awarded $2.4 million to Ashley Shepherd, "who claimed Highlands ARH Medical Center retaliated against her after she refused to go along with an alleged scheme to boot out suicidal, psychotic and homicidal patents when their insurance coverage expired, usually after three days," Wolfson reports. "Shepherd, a behavioral therapist, said she was directed by supervisors at the hospital in Prestonsburg to persuade patients they were no longer psychotic, suicidal or homicidal so they could be discharged when they could no longer pay or their insurance coverage ran out."

Shepherd, a 36-year-old single mother, testified in a deposition, “I was told this is not a hotel.” ARH denied the charges, but the jury said it should pay $2 million in punitive damages.

On Sept. 13, a federal jury in Louisville "awarded $2,395,000 to tow-truck operator William “Tully” Williams, 65, whom Baptist Hospital Lexington turned away when he was transported there by EMS suffering from a dangerous type of heart attack" on Final Four weekend in April 2015, Wolfson reports. "The hospital said it had to 'divert' heart-attack patients because it didn’t have any cardiothoracic surgeons on call. . . . He had to be loaded back into an ambulance and taken to another hospital down the road. . . . His lawyer, Hans Poppe, said the hospital committed a 'reckless comedy of errors,' including failing to advise local ambulance services of its plans."

Williams sued Baptist Health after the federal government found that the hospital violated the Emergency Medical Treatment and Labor Act by failing to screen and stabilize Williams before sending him to the University of Kentucky hospital a mile away, Wolfson reports. The law allows fines of up to $100,000, or lets patients sue for more.

Baptist Health attorneys argued that the delay was "only a few minutes, but its own medical expert conceded it didn’t meet the standard of care," Wolfson reports. The jury's verdict included $1.85 million in punitive damages, which are designed to discourage similar conduct by the defendant and others. The case was tried by District Judge Claria Horn Boom.

Shepherd's attorney, Jerry Patton of Prestonsburg, told Wolfson that his client's award “sends a message to health-care providers who bear tremendous responsibility for the treatment and care of psychiatric patients that the law must be followed, and above all patient safety and care is paramount to any and all other considerations, including profit.”

Appalachian Regional Healthcare's chief legal officer, Cristi R. Lee, gave Wolfson a statement: “Patient care is always the top priority in all ARH locations, regardless of that patient's ability to pay. Additionally, processes are in place to encourage all staff to make their voices heard should they want to suggest opportunities for improvement or have any concerns while working in our facilities.”

"She noted the case, tried before Judge Thomas Smith, involved one claim related solely to Shepherd’s employment and there were no claims of medical negligence," Wolfson reports. "She said ARH was disappointed with how the law was applied and has asked Smith to overturn the verdict."

In the other case, Baptist Health spokeswoman Kit Fullenlove Barry told Wolfson that the diversion of Williams said was a “rare and unusual occurrence. . . . While we are surprised and disappointed with the verdict, we are pleased that Mr. Williams received the care he needed and is doing well.” Baptist "said it later hired a consultant to train employees how to comply with the law," Wolfson reports.

New law protects consumers from surprise medical bills

Graphic from Centers for Medicare and Medicaid Services

By Melissa Patrick

Kentucky Health News

As of Jan. 1, Americans who get surprise medical bills have new federal consumer protections. 

"This new law will help make sure our people have protection against unexpected medical bills in an emergency," Gov. Andy Beshear said in a news release. Congress passed the law more than a year ago but delayed its effective date.

In 2018, the Altarum Healthcare Value Hub found that nearly a third of privately-insured Kentucky adults received an unexpected medical bill either in an amount that was higher than expected, from a doctor they didn't expect or from a doctor that they thought would be in-network, but wasn't. 

Surprise medical bills happen when an insured person inadvertently receives care from an out-of-network hospital, doctor or other provider that they did not choose and are then required to pay out-of-pocket for that out-of-network care. 

For example, before the new law, even if you used an in-network hospital for an elective procedure, you would be responsible for the balance of any medical bills that were charged by an out-of-network provider, which often showed up in services like anesthesia, imaging and laboratory work. 

The new law says patients cannot be asked to pay more than the in-network rate their insurer would typically charge them. 

It also addresses "balance billing," the practice of allowing an out-of-network provider or facility to bill you for the difference between the billed charge and the amount your health plan paid. 

The new rules ban four key things: surprise billing for emergency services; balance billing and out-of-network cost-sharing; out-of-network charges and balance billing for ancillary care; and certain out-of-network charges and balance billing without advance notice, says a Kentucky Voices for Health blog post.

There is at least one gap in the law. It applies to air ambulances, both emergency and non-emergency, but not to ground transportation.

The legislation covers people covered under employee-sponsored and individual/family health plans for plan years beginning on or after Jan. 1, 2022. If you have coverage through Medicare, Medicaid, Tricare, Veterans Affairs health care or Indian Health Services, you’re already protected against surprise medical billing, Kentucky Voices for Health says.

The federal government estimates that the law will apply to about 10 million out-of-network surprise medical bills each year.

Kaiser Family Foundation research found that about one out of five emergency room visits and between 9% and 16% of in-network hospitalizations involve a surprise medical bill. Another study, published in JAMA Network, found it happens to about one of five insured people, adding an average of $2,011 more to the bill.

Kentuckians with a complaint about a surprise bill can contact a new federal hotline, the "No Surprises Help Desk" at 800-985-3059 or visit the federal website at https://www.cms.gov/nosurprises for helpful resources. You can also contact the Kentucky Department of Insurance at 800-595-6053

Examples of how the new protections apply can be found on the DOI website at https://insurance.ky.gov/ppc/Documents/nsa%20-%20consumer%20bulletin%2012-2021.pdf.

In addition, the Kaiser Family Foundation offers a short video to describe how these new protections work for patients. It also offers a detailed summary of the Act.

New legal age of 21 to buy tobacco products surprises some; anti-smoking leaders say it won't thwart teenagers' use of e-cigarettes

By Melissa Patrick
Kentucky Health News

The minimum age to buy tobacco products, including electronic cigarettes, is now 21.

Legislation to raise the age from 18 passed Congress as part of the year-end spending bill and was signed into law by President Trump Dec. 20.

The "Tobacco 21" legislation, co-sponsored by Senate Majority Leader Mitch McConnell, R-Ky., and Sen. Tim Kaine, D-Va., gave the federal government up to nine months to develop and implement the regulation, but the U.S. Food and Drug Administration issued a statement on its website the same day the bill was signed into law to make the new age threshold effective immediately.

The statement said, "It is now illegal for a retailer to sell any tobacco product – including cigarettes, cigars and e-cigarettes – to anyone under 21. FDA will provide additional details on this issue as they become available." Dr. Stephen M. Hahn, the FDA commissioner, tweeted that "more details will be forthcoming as we update our regulations to carry out this provision of law."

Some health advocates have praised the change as a way to reverse the surge in teen use of e-cigarettes, but others say it's an important move that doesn't go far enough. They say tobacco companies supported it to avoid heavier restrictions on e-cigarettes, the use if which is epidemic among teenagers.

Ellen Hahn, a University of Kentucky nursing professor and the longtime leader in Kentucky tobacco-prevention efforts, and Audrey Darville, a tobacco treatment specialist at UK, told Kentucky Health News in an e-mail, "Raising the minimum age of legal sale of tobacco products to 21 years is a step in the right direction, but without also prohibiting all flavored tobacco products, the Tobacco-21 law will not stop the youth e-cigarette epidemic."

They added later, "Keep in mind that the tobacco industry wants to do all they can to avoid FDA regulation for new products, so agreeing to Tobacco-21 (without flavor restrictions) is a pro-industry, not a pro-public health strategy."

On Jan. 2, the FDA announced a ban on the sale of flavored e-cigaretttes except menthol and tobacco-flavored products for closed systems, like Juul pods. The ban does not include flavors in tank systems sold in vape shops; the FDA says this concession was made to support adults who use e-cigarettes as a aid to quit traditional cigarettes.

Health and Human Services Secretary Alex Azar said in a news release that HHS "seeks to strike the right public health balance by maintaining e-cigarettes as a potential off-ramp for adults using combustible tobacco while ensuring these products don’t provide an on-ramp to nicotine addiction for our youth."

The key word in that sentence is "potential." The FDA has not approved any e-cigarette product as a smoking-cessation aid, and the smokefree.gov website says, "So far, the research shows there is limited evidence that e-cigarettes are effective for helping smokers quit."

Quick change surprises many

Several national organizations weren't happy with the abrupt change and sent the FDA a letter Dec. 27 stating the challenges it presents to retailers and consumers. The letter asked that the new threshold not be enforced until the FDA updates its regulations and offers clear direction.

On Jan. 2, one of the groups that signed the letter, the National Association of Convenience Stores, urged compliance with the new threshold, despite questions about its implementation.

"While there are unanswered questions about when FDA plans to enforce this requirement and whether the agency can legally enforce it before updating its regulations, retailers should be aware that FDA views any sale to a person younger than 21 as a violation of the new law," the association said in its newsletter..

A manager at a tobacco shop in Owensboro said the change has upset some of her customers, Trey Crumbie reports for the Messenger-Inquirer.

Elizabeth Leary, manager of River's Edge Tobacco Outlet, told Crumbie that 20 to 30 percent of her clientele is in the 18-to-20-year-old range. The outlet sells both traditional tobacco products and vaping products.

Leary added that while she hated to see young people smoking, she didn't think raising the age of purchase to 21 would curtail vaping among teens.

"They're going to find a way," she told Crumbie. "You can change the laws all you want but people find a way to get what they want, one way or another. And what the scary part is if they can't come here and get something that's legit, they'll go in the back alleys and get the stuff that's been causing people to get sick."

More than 6 million U.S. middle and high school students are current users of tobacco products, and 5.3 million of them, or 85 percent, are using e-cigarettes, according to the latest annual National Youth Tobacco Survey.

The latest data for e-cigarette use by Kentucky teens, from 2018, shows e-cig use had nearly doubled since 2016, with more than one in four high-school seniors and one out of seven eighth-graders reporting they used the devices, the Kentucky Incentives for Prevention study found.

The state legislature, which convenes Jan. 7, will need to change state law to comply with the federal statute. Sen. Ralph Alvarado, R-Winchester has already prefiled a bill to do so.

McConnell and electronic-cigarette firms' bill to raise legal age to buy tobacco and e-cigarettes to 21 awaits president's signature

By Melissa Patrick
Kentucky Health News

Legislation to raise the nationwide legal age to buy tobacco produces, including electronic cigarettes, from 18 to 21 passed Congress as part of the year-end spending bill and went to President Donald Trump for his expected signature. It passed the House Dec. 17 and the Senate Dec. 19.

“I’m proud the Senate approved legislation today including our Tobacco-Free Youth Act to help address this urgent crisis and keep these dangerous products away from our children," Senate Majority Leader Mitch McConnell, who engineered the move, said in a news release.

U.S. Sen. Tim Kaine, a Democrat from Virginia, who co-sponsored the measure, called its passage an "enormous victory for the health of our young people" and said in addition to reducing youth tobacco use, it would save 223,000 lives.

"This is one of many steps we should take to tackle the youth e-cigarette epidemic that touches every corner of our nation," Kaine said in a news release.

More than 6 million U.S. middle and high school students are current users of tobacco products, and 5.3 million of them, or 85 percent, are using e-cigarettes, according to the latest annual National Youth Tobacco Survey.

The latest data for e-cigarette use by Kentucky teens, from 2018, shows e-cig use had nearly doubled since 2016, with more than one in four high-school seniors and one out of seven eighth-graders reporting they used the devices, the Kentucky Incentives for Prevention study found.

“The dangers of nicotine on young people’s development—especially on their brains and lungs—can inflict life-long damage. Raising the minimum tobacco purchase age to 21 will help keep these harmful products away from our kids, and I can’t thank Senator McConnell enough for his vision and leadership for our children’s future," state Rep. Kim Moser, R-Taylor Mill, chair of the state House Health and Welfare Committee, said in McConnell's release.

In a separate release issued earlier this week,  Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, praised McConnell's work. He added that the state legislature, which convenes Jan. 7, will need to change state law to comply with the federal statute. Sen. Ralph Alvarado, R-Winchester, has prefiled a bill to raise Kentucky's legal age to 21 from 18.

"This bill is a critical step toward reversing the skyrocketing rates of youth vaping nationwide and in Kentucky," Chandler said. "We encourage the Kentucky legislature to demonstrate similar leadership in passing Sen. Alvarado's Tobacco 21 bill quickly this coming year."

A similar bill was introduced in the last legislative session, but tobacco-friendly senators blocked it.

Terry Brooks, executive director of Kentucky Youth Advocates, also praised the legislation.

"Kentucky Youth Advocates thanks Leader McConnell for leading the way in Congress on this critical issue to help keep Kentucky kids—and kids across the nation—healthier and prevent life-long addiction to nicotine," Brooks said in a statement.

Already, 19 states have raised the tobacco age to 21, along with Washington, DC and over 530 localities, although the strength of their laws vary substantially, according to the Campaign for Tobacco-free Kids. E-cigarette companies see the law as a way to limit other forms of regulation aimed at limiting smoking and e-cig use by teenagers.

In the latest Kentucky Health Issues Poll, six in 10 Kentuckians said they would support increasing the minimum age to purchase tobacco products to 21, with majorities in each political party.

In addition to Alvarado's bill, Kentucky lawmakers have pre-filed several other bills to thwart the surge in teen use of e-cigs, including one to ban the sale of flavored e-cigs; one to impose registration and licensing requirements to sell them; and one to tax them at the same rate as traditional cigarettes.

McConnell files bill to raise legal age to buy tobacco products to 21, with some provisions Kentucky health advocates wanted

By Melissa Patrick and Al Cross
Kentucky Health News

Senate Majority Leader Mitch McConnell today introduced his promised bill to raise to 21 from 18 the legal age to buy tobacco products in the United States, in response to what he called a public-health epidemic of electronic-cigarette use by teenagers.

Senate Majority Leader Mitch McConnell talks tobacco.

"Youth vaping is a public health crisis," McConnell said during a floor speech to introduce the bill. "It's our responsibility as parents and public servants to do everything we can to keep these harmful products out of high schools and out of youth culture. We need to put the national age of purchase at 21."

Most adults who smoke start before they turn 21, so increasing the tobacco age to 21 will keep youth from starting, save lives and improve public health, says the Institute of Medicine. McConnell said he would make enacting the bill one of his highest priorities.

McConnell's co-sponsor is Sen. Tim Kaine, D-Va. "As senators from two states with a long history of tobacco production and consumption, [they] have seen this phenomenon firsthand, and heard the compelling stories from concerned constituents throughout their states," said a short explanation of the bill and the reasons for it. The bill is called the Tobacco-Free Youth Act.

McConnell gave a detailed history of how tobacco helped shape the nation and Kentucky. He said the state had almost 30,000 tobacco farmers when he helped end the federal tobacco program in 2004, but now has only 2,600.

"For many in Kentucky, tobacco made the American dream possible," he said, but also talked about the negative impact tobacco has had on Kentuckians' health. The state leads the nation in cancer and the percentage of cancers tied directly to smoking. "Our state once grew tobacco like none other — and now we’re being hit by the health consequences of tobacco use like none other," he said. "We’re proud of our past, we’re proud of who we are, but Kentucky farmers don’t want their children to get hooked on tobacco products while they’re in middle school or high school anymore than any parent anywhere wants that to happen. . . . The health of our children, literally, is at stake.”

According to the Kentucky Incentives for Prevention survey, teen use of electronic cigarettes in Kentucky nearly doubled from 2016 to 2018. The survey found that 26.7% of the state's high-school seniors reported using e-cigarettes in the 30 days before they were surveyed in 2018, up from 12.2% in 2016. Among 10th graders, it increased to 23.2% from 11.3%; eighth graders jumped to 14.2% from 7.3%; and sixth-grader use increased to 4.2% from 2.3%.

McConnell pointed to a nationwide survey that found the use of tobacco products increased by nearly 40% between 2017 and 2018, driven almost entirely by vaping. "The brain is still developing at this young age. When teenagers use tobacco, they're quite literally altering their brain chemistry and making it more susceptible to addiction," he said.

Enforcement is up to the states

Federal law does not establish a penalty for violating the current age limit of 18, but leaves enforcement up to the states and makes certain federal grants dependent upon enforcement.The McConnell-Kaine bill would leave that system in place. Laws in Kentucky and many other states have penalties for under-age youth who buy, possess or use tobacco products.

Advocates will have to work with state legislators to remove those laws, said Bonnie Hackbarth, vice president for communications at the Foundation for a Healthy Kentucky, which has endorsed McConnell's bill.

"Our interest was to make sure that there was nothing in the federal bill to impose penalties on the actual purchaser, but to rather put those penalties on the retailers where they should be and that is the way the bill is written," Hackbarth said. "That would be our goal, that the penalties would be on retailers and not the purchasers."

Foundation President and CEO Ben Chandler said in a news release, “Since Sen. McConnell stood in our offices just last month and announced plans to file this bill, new data has come out showing that youth e-cigarette use in Kentucky doubled over the past two years. We’re gratified that the provisions we sought to help reduce this explosion in youth vaping and other tobacco use have been included in the bill: It covers all tobacco products, including e-cigarettes as well as heated products; it prohibits sales to everyone under age 21, with no military exemption; it puts responsibility for compliance where it should be – on retailers, and it preserves the right of states to enact stricter laws.”

Chandler added, “We urge Congress to pass this bipartisan bill quickly and states to begin getting their own T21 bills in order. Every extra day it takes to put this important legislation into effect is an opportunity for thousands more kids to access a tobacco product that can damage their developing brains now and cause debilitating health issues throughout their lives.”

The bill has already received the support of several organizations, but others are being more cautious before they give it their approval.

"Increasing the minimum sale age for all tobacco products to 21 offers a common-sense way to keep harmful tobacco products out of reach of our kids and prevent life-long addictions to nicotine," Dr. Terry Brooks, executive director of Kentucky Youth Advocates, said in a release. "We urge Congress to support this bipartisan bill and for our leaders in Frankfort to begin work aligning state law to protect more youth from the lasting harms of tobacco use."

Some advocates want more

The American Lung Association also supports the bill, though it calls for more action, including a ban on flavored tobacco products, restricting online sales of the products and increasing funding for the Centers for Disease Control and Prevention's Office on Smoking and Health.

The Campaign for Tobacco-Free Kids said it was still evaluating the bill to make sure it is strong enough, including strong enforcement penalties on retailers, no exemptions and no "special interest provisions that block other policies needed to protect kids and public health, such as prohibitions on flavored tobacco products."

With the support of McConnell and Kaine, the bill is expected to have little trouble in the Senate, but its House prospects "are unclear," The Wall Street Journal reports. "House Democratic aides said they are still reviewing it, though they pointed to more expansive legislation introduced in the House that would also restrict flavored e-cigarettes and regulate marketing to young people, among other measures, in addition to raising the age for purchasing tobacco. Legislation that takes similar measures—but doesn’t raise the purchasing age—has received bipartisan support in the Senate."

McConnell's bill addresses some of the advocates' concerns. It does not exempt people in the military, as he originally said it would, and it would allow states to pass stronger tobacco laws.

McConnell told Deborah Yetter of the Louisville Courier Journal that he was aware of health advocates' concerns that tobacco companies support the legislation only because it could shield them from more aggressive enforcement and a possible ban on flavorings.

"Just the fact that they're for it doesn't mean it's a bad idea," he said. "This is just a floor, not a ceiling. I don't think it relieves them of any of the battles they're going to have to fight at the state and local levels in the future."

A bill to raise the legal age to buy tobacco products in Kentucky failed in the last session of the legislature, after opponents said it would hurt the tobacco industry. The bill, and similar legislation passed in Virginia and 13 other states, is backed by Virginia-based Altria Group, the nation's largest cigarette maker. Altria recently bought 35% of Juul Labs, maker of the most popular e-cigarette.

Congress sends President Trump a huge, comprehensive, bipartisian bill to fight the opioid epidemic; he says he will sign it

By a 98-1 vote Wednesday, the Senate passed the final version of a comprehensive package to address the opioid epidemic and sent it to President Donald Trump, who is expected to sign it "just in time for lawmakers to campaign on the issue before the November elections," Colby Itkowitz reports for The Washington Post.

Sen. Mike Lee (R-Utah) cast the only opposing vote. The House passed its version of the bill last week 393-8. Trump issued a statement saying "I look forward to signing this historic legislation."

The 653-page bill "unites dozens of smaller proposals sponsored by hundreds of lawmakers, many of whom face tough reelection fights," Itkowitz notes.

Senate Majority Leader Mitch McConnell noted that more people in recovery will have access to housing and work opportunities because of his legislation that was included in the package. "With today’s vote, the Senate will say this to every American affected by the opioid epidemic: America is fighting back against this crisis," said McConnell, who is already running for re-election in 2020.

Considered one of Congress's most significant legislative achievements this year, the legislation "creates, expands and reauthorizes programs and policies" and addresses both law-enforcement and public health measures, particularly around prevention, treatment and recovery, Itkowitz reports.

Associated Press photo by Patrick Sison

Opioid overdoses were responsible for nearly 50,000 U.S. deaths last year, 1,565 in Kentucky.

Itkowitz reports that Sen. Rob Portman (R-Ohio), "who sounded the alarm on opioid addiction four years ago," is credited with the bill's provision that will require the U.S. Postal Service to screen packages for synthetic fentanyl shipped from overseas, mainly China.

Portman said in a floor speech Tuesday, “How many people had to die before Congress stood up and did the right thing with regard to telling our own post office you have to provide better screening?”

Among other things, the legislation allows more health-care providers to prescribe medication for opioid addiction; will make it easier for Medicaid recipients to get inpatient care for substance abuse over the next five years; and provides funds for the research and development of new, non-addictive painkillers. It would also create a grant program for comprehensive recovery centers that include housing and job training, as well as mental and physical health care.

Public-health advocates are pleased with the bill's increased attention to treatment, but "many experts" are concerned that it doesn't dedicate enough long-term funding to fight a crisis of this magnitude, Itkowitz reports.

“This legislation edges us closer to treating addiction as the devastating disease it is, but it neglects to provide the long-term investment we’ve seen in responses to other major public health crises,” Lindsey Vuolo, associate director of health law and policy at Center on Addiction, told Itkowitz. “We won’t be able to make meaningful progress against the tide of addiction unless we make significant changes to incorporate addiction treatment into the existing health care system.”

Congress has appropriated $8.5 billion this year for opioid-related programs, but there’s no guarantee of funding for subsequent years, Itkowitz reports.

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.

McConnell says his bill wouldn't take anyone off Medicaid; critics of the bill say it would, starting with some children, then adults

McConnell in Paducah July 5

(Photo by Nicole Erwin, WKMS-FM)

By Melissa Patrick and Al Cross
Kentucky Health News

At a July 5 luncheon in Paducah, Senate Majority Leader Mitch McConnell said, “Nothing we've advocated so far would cause anyone currently on Medicaid to come off of it,” Adam Morton reports for the West Kentucky Star.

Not directly, perhaps, but likely indirectly, especially for the 475,000 children and adults who are covered by the expansion of Medicaid under the Patient Protection and Affordable Care Act. That's because the bill McConnell has been pushing would reduce the money the federal government gives the state to pay their medical bills.

After the completion of that reduction, in 2024, the bill would then limit the money that the federal government gives the state for traditional Medicaid, rather than the current system of reimbursing the state a percentage of what it spends, called the Federal Medical Assistance Percentage, or FMAP. Currently, for traditional Medicaid, Kentucky gets about 70 percent. For expanded Medicaid, it gets 95 percent this year, declining in annual steps to the current law's floor of 90 percent in 2020.

McConnell spokesman Robert Steurer referred to the FMAP when asked to explain the senator's comment. “Those who are currently on Medicaid can remain on Medicaid,” he said in an email. “Beginning in 2021, the enhanced rates for the expansion population will begin to gradually decline by 5 percentage points (meaning states will gradually pay more of their share for the expansion group) until 2024 when the state will receive the normal FMAP.”

Steurer added that the Congressional Budget Office “believes some people will ‘choose’ to leave Medicaid over the next four years, but does not say they will be forced” by the Better Care Reconciliation Act, which McConnell is pushing.

Medicaid is not a static program. Many people go on and off of it each month, as their incomes and situations change. Three years ago, that “churn” was about 30,000 a month. Those on the program when the legislation takes effect "would not be the same population of people who are 'currently' on Medicaid," Michelle Ye Hee Lee writes in The Fact Checker column in The Washington Post. "Some people may leave Medicaid if, for example, they had access to employer health insurance. They may not be able to get back on Medicaid if they sought to later, if the eligibility changes."

The Post goes on: "The bill does not require or direct states to change Medicaid, and states run their own Medicaid programs. This is the crux of McConnell’s argument. States can make choices that are best for them regardless of BCRA, and it doesn’t mean that federal law would 'cause' these changes, explained McConnell’s staff. Some states would choose to keep their current level of Medicaid coverage, and change their state budget priorities to make that work. But some states would scale back or eliminate coverage for newly insured Medicaid populations because of the financing changes in BCRA, according to CBO."

Kentucky ACA advocates disagreed with McConnell's assertion that the Senate bill won't cause anyone now on Medicaid to lose their coverage.

“I can't begin to understand why he said that,” said Dustin Pugel, a research and policy associate for the liberal-leaning Kentucky Center for Economic Policy.

He said some children on Medicaid would lose coverage under the Senate bill, because “The eligibility threshold for kids between 6 and 16 goes from 138 percent down to 100 percent” of the federal poverty level.

Pugel said elimination of the increased funding for the expansion is almost certain to cause people in Kentucky to lose coverage.

“Kentucky would have to come up with 405 million dollars each year just for the expansion, just to maintain the expansion,” he said. “We almost certainly wouldn't do that. I really don't think that our state government would decide to cough up that much money for Medicaid expansion considering all the talk around our pension crisis and budget shortfalls.”

State Budget Director John Chilton said in May that Kentucky needs an additional $700 million a year to “responsibly tackle” its pension crisis. Gov. Matt Bevin has said he will call a special legislative session this year to address it.

Emily Beauregard, executive director of Kentucky Voices for Health, an organization of pro-ACA groups, called McConnell's statement misleading. She said the CBO analysis estimates “that states will simply not be able to shoulder that additional cost and therefore will cut their Medicaid expansion programs if they have them.”

The CBO estimates that of the 22 million people by 2026 who lose coverage, 15 million of them will be Medicaid enrollees. “And in Kentucky, the Urban Institute says that 704,000 of that 15 million are going to be Kentuckians,” Pugel said.

The estimates are based partly on a new per-person limit that the bill would place on state Medicaid funding. The amount would increase each year, but not enough to keep up with inflation in health-care costs, the bill’s opponents say.

“The state's going to have less and less money to be able to pay for the same amount of care or more care,” Pugel said. “The state is going to have to either cover fewer people, cover fewer benefits, or pay providers even less." They already complain about reimbursement rates.

The CBO estimates a 26 percent reduction in the purchasing power of Medicaid in the first 10 years under the Senate bill is enacted, and 35 percent in the second 10 years.

“The bottom line is they are cutting federal funding to the Medicaid program by $770 million, which will result in people losing coverage and I don't think there is another way to interpret that,” Beauregard said. “Whenever you cut a federal program like that, it directly results in people losing coverage and you can't say otherwise and it be accurate.”

Pugel said he would like to ask McConnell how he expects Kentucky to maintain the state's Medicaid enrollment levels with such cuts: "There are estimates that Kentucky could see as much as a 58 percent decrease in federal funding for Medicaid,” he said. “I don't think you could absorb that kind of a cut without people losing coverage.”

McConnell's office didn't respond to a request for comment on Pugel's and Beauregard's remarks. On Monday, he gave a speech about how his bill would address problems with private insurance in Obamacare, but made no mention of Medicaid.

The Post's "Fact Checker" column gives McConnell's statement about Medicaid three Pinocchios out of four, meaning that it is "deeply misleading": "McConnell pushed the envelope here. The reality is that BCRA is the potential intervening factor for whatever choices states would make in response, and CBO estimated it would lead to 15 million fewer Medicaid enrollees by 2026, compared to current law." Here's a video report from the Post:

Consulting firm's study says health bills pending in Congress would put more Kentucky rural hospitals into the red

By Melissa Patrick
Kentucky Health News

Rural health care and related jobs will take a huge hit if Congress rolls back the Patient Protection and Affordable Care Act as Republicans have proposed, says an analysis from the Chartis Center for Rural Health, part of a national health-care advisory firm.

The report says 41 percent of the nation's 2,200 rural hospitals already lose money and any revenue loss "will further weaken their tenuous financial position." It estimates that the proposed cuts to Medicaid would push the percentage of rural hospitals operating in the red up to 48 percent. Further, it says hospitals will be forced to cut employees and costs to adjust to the decreasing revenue.

Nationally, the analysis of the House and Senate bills estimates between 34,000 and 37,000 rural health-care and related jobs would be lost as a result. In Kentucky, those job losses are estimated to be between 2,278 and 2,461.

It also estimates that nationally, proposed cuts to Medicaid will result in an annual $1.4 billion loss of revenue to rural health providers if the House bill is enacted, and an annual $1.3 billion loss under the Senate bill. In Kentucky, the projections say rural hospitals would lose $90 million annually if the House bill is enacted, and an annual $83 million loss under the Senate bill.

Further, the report breaks down the projected revenue and job losses for the 66 rural Kentucky hospitals analyzed in the study.

It found that Saint Joseph London is projected to have the most job losses, losing between 113 and 122 jobs; followed by Clark Regional Medical Center in Winchester, projected to lose between 107 and 116 health related jobs. TJ Samson Community Hospital in Glasgow is projected to lose the most revenue under both bills -- around $5 million annually-- and is estimated to lose between 98 and 106 health related jobs.

The report notes that states such as Kentucky, which chose to expand Medicaid under the ACA, would see cuts nearly double those of states that didn't expand Medicaid; and that states with larger Medicaid programs and larger rural populations would see a greater impact from the proposed cuts. Kentucky falls into both categories.

Kentucky is one of the 31 states that expanded Medicaid under Obamacare to those who earn up to 138 percent of the federal poverty line. Around 470,000 Kentuckians gained health insurance through the expansion. About 1.4 million people are covered by Medicaid in Kentucky.

Most of the Medicaid cuts would come from phasing out the extra funding for the Medicaid expansion. Under the ACA, the federal government pays 95 percent of the expansion funding this year, rising decreasing in annual steps to the ACA's 90 percent limit in 2020. The House bill phases this out in 2020; the Senate bill keeps it until 2021, but then cuts it back to the traditional Medicaid level over the following three years.

The federal government pays an average of 57 percent of traditional Medicaid costs, but the rates vary between 50 and 75 percent, with poor states getting a higher percentage. The federal government pays 70 percent of the costs for traditional Medicaid in Kentucky.

Long-term cuts to Medicaid would come from a change in how traditional Medicaid funding is calculated. Both bills would move funding to a formula that is based on population instead of reimbursing a state a percentage of what it spends, based on a formula that gives poorer states more money. The Senate bill could change on that point to get the votes needed for passage.

"Both pieces of legislation make significant cuts to Medicaid, which will have far reaching implications for the neediest communities and the providers who serve them," Michael Topchik, national leader for the Chartis center and senior vice president at iVantage Health Analytics, said in a news release.

The Congressional Budget Office estimates that by 2026, Medicaid spending under the Senate bill would be 26 percent less than projected under current law; the House bill would reduce it by 24 percent.

Letcher County residents' message: 'Don't take away our health care'; doctor says almost half his patients are on Medicaid

Letcher County residents voted overwhelmingly for President Trump largely because of his pledge to re-open the region's coal mines, but many are now worried about what will happen to their health insurance if Congress passes legislation that makes cuts to Medicaid, Laura Bicker reports for BBC News.

The Republican majorities in Congress are working to repeal and replace the Patient Protection and Affordable Care Act, and both pending bills would phase out extra funding for the Medicaid expansion, likely making the program too expensive to maintain at regular federal funding rates. In addition, later changes in how traditional Medicaid is funded would significantly decrease the amount of money available to the program as well.

Claude Lucas, 51, who was a coal miner for 27 years and has black-lung disease, told Bicker that he is worried, adding that Medicaid had saved his life because it pays for his medication and treatments. Lucas is unable to work and lost his health insurance when the mine closed.

Dr. Breeding works 16-hour days. Photo: BBC News

Lucas is a patient of Dr. Van Breeding, a primary-care physician and clinical director at Mountain Comprehensive Health Corp.

Breeding, a Letcher County native, told Bicker that he is afraid Washington is so busy with the politics of the bills that they have forgotten about the health issues that he deals with daily.

Kentucky has some of the highest rates of cancer, heart disease, diabetes and obesity in the nation, and the rates are often highest in Eastern Kentucky, to say nothing of the opioid epidemic.

"There shouldn't be any sides. There are no sides to this. The only side is great health care for every American," said Breeding, who was named Staff Care's 2017 Country Doctor of the Year. He added that he believes lawmakers should be looking at the healthcare models used in the United Kingdom and France.

"Other countries have done it. They've set the groundwork for us. We can take what they've done and use it and build on it to make it the best program in the world," he said. "That's why the United States is as strong as it is. We've always taken things and made them better. Why can't we take a healthcare product and make it better instead of fighting over it."

Eighty percent of Letcher County voters chose Trump, who not only promised to bring coal jobs back to the county, but promised not to cut Medicaid.

Caherine Collins, who is paralyzed and has been in a wheelchair since her car accident 12 years ago, and depends on Medicaid for her care, told Bicker that she is angry about these broken promises.

"I think Donald Trump is just taking into consideration his concerns and he's not thinking about the little people," Collins said. "I don't know what he's thinking. He promised a lot to get in the office. And he's went back on a lot. Big words were spoken. A lot of lies were told by him."

But Matthew Caudill told Bicker that Obamacare has "been a real mess for him and his family" because of the increase in his premiums --up to $400 a month for himself and two children from $43 a month -- and high deductibles.

"It has devastated my family's coverage. I find myself unable to feel sorry for anybody else when my children's coverage is so poor. I must worry about my family first. If nothing changes then this will get much worse in the coming years," he said.

Obamacare requires plans to cover 10 essential benefits and no longer allows insurance companies to not cover pre-existing conditions, provisions that have caused many premiums to rise. Both provisions are at risk of being removed in Congress. In addition, uncertainties about the subsidies that make health insurance more affordable and the individual and employee mandates have caused premiums to soar recently.

Another Breeding patient is Cortney Akeman, who is four months pregnant and part of a program that helps pregnant mothers who are addicted to drugs wean off of them so that their babies aren't born addicted. The program is covered by Medicaid, "but that is being reconsidered in the latest draft of the health bill," Bicker notes.

Breeding, who said almost half of his patients are on Medicaid, believes this type of preventive medicine will save money in the long run and should help break the cycle of abuse.

He added, "I think we all should have the same insurance. If we said that from President Trump down to me and any of my patients that we all had the same insurance I think we would all be bought into making sure that it worked right for everyone."

Bicker writes, "The cry I heard over and over from Letcher County was the same. Don't take away our health care." 

Danville paper looks at how the proposed health law would affect the local community

Danville's newspaper, The Advocate-Messenger, broke down and localized the potential impacts of the latest health bill in Congress.

Reporter Bobbie Curd first walked her readers through the Senate bill, noting how it compares to the House-passed health bill and the Patient Protection and Affordable Care Act, then showed how the proposed changes to Medicaid could affect Boyle County.

About 1.4 million people are covered by Medicaid in Kentucky, 470,000 of them through the expansion of the program to people who earn up to 138 percent of the federal poverty line. As of May 2017, Medicaid covers 8,517 people in Boyle County, Curd reports.

Under the repeal-and-replace bill passed by the House, the extra money for Medicaid expansion would end in 2020. Under the Senate bill, current funding would remain the same until 2021, but would be cut back to the traditional Medicaid level over the following three years.

In Kentucky, the federal government pays about 70 percent of costs for traditional Medicaid recipients and 90 to 95 percent for expansion members.

Both bills would cut federal support for traditional Medicaid, through spending limits that wouldn't keep pace with health-care costs. Experts say these cuts will cause states to either raise taxes, cut eligibility or cut benefits in order to maintain their programs.

Local health professionals and lawmakers in Boyle County told Curd what these changes to Medicaid would mean for their community.

County Public Health Director Brent Blevins said people who lose health coverage would have to resume using the emergency room and the health department. “You’re going to see people showing up needing primary care or specialized care that we don’t have,” he said. “Most of ours is preventative care, so where are those people going to go?”

Sarah Hempel is the office manager for her husband Dr. Rick Hempel, a geriatrician in Danville. She told Curd that the need for primary care is so great that they have had to “drastically change their practice” -- seeing 30 to 40 patients a day, making it hard to give quality care.

New doctors “won’t even go into primary care anymore,” she said. “There’s a huge primary-care shortage in this area — it almost has to be a calling,” she said.

Dr. Jeremy Stich of Access Med, a direct-care system where insured patients pay a flat monthly fee with no co-payments, voiced concern that the Senate bill was drafted without input from providers.

“It concerned me when it was done by non-clinicians,” he told Curd. “Too many politicians and too many lobbyists involved. It was the same with Obamacare. That hasn’t changed.”

Danville attorney Mark Morgan, who represents disabled people, told Curd, “I was going to three, maybe four funerals a year for clients who had passed away,” he says — direct results of not getting medical care or medicines. “When Medicaid expanded in Kentucky, that stopped happening. It was a day-and-night transformation. Most of the bad outcomes disappeared.”

He added, “I’m fearful that we’re going to return to the situation we were in before, sitting across the desk from people who can’t get diagnostic testing, can’t get meds and scripts, and I’m going to be going back to funerals again.”

Curd points out that affording health care is not just a challenge for the poor, but for the middle class because of the "surging bite of higher premiums and ridiculously large deductibles."

Blevins said the health department sees many middle-class people looking to afford their care: “I think more middle-class people are really struggling these days. These are families who are going to work every day, trying to pay their bills, not living outside of their means, giving to charity when they can, but are still struggling trying to pay medical bills. I think there’s a lot out there like that we don’t realize it.”

Stich added that working families are struggling to afford health care and are "literally faced with losing their home or their kids dropping out of college because they can’t afford it."

Morgan said, “The people we represent say frequently, ‘OK, I won’t get the medicines or go to the doctor,’ and I end up seeing them in the funeral home. And I’m tired of it, and I don’t want to see it any longer. Certainly not so that taxes can be cut for the wealthy.”

Low-income adults in Medicaid expansion in Kentucky and Arkansas report better health and medical care, study finds

By Melissa Patrick
Kentucky Health News

Two states that expanded Medicaid through the Patient Protection and Affordable Care Act showed a 41 percent increase in the number of enrollees with a regular health-care provider and a 23 percent increase in the share who report excellent health, according to a three-year study of Kentucky and Arkansas.

The study also found that low-income adults with chronic diseases in the two states were more likely to report that they had better health, were getting regular care and were able to afford their medications.

Kentucky and Arkansas and Kentucky both expanded Medicaid to people who earn up to 138 percent of the federal poverty line, but in different ways. Kentucky expanded Medicaid while Arkansas used federal Medicaid funding to provide private insurance to its low-income adults. The study compared them to Texas, which did not expand the program.

The report said that while Arkansas and Kentucky took different approaches to Medicaid expansion, the benefits to enrollees were nearly equal between the states.

“The Affordable Care Act is leading to substantial improvements in health care for low-income adults in Arkansas and Kentucky, and people report that their health is better too,” Dr. Benjamin Sommers, lead author of the study, said in a news release. “In contrast, many low-income adults in Texas continue to lack insurance and more frequently have to skip needed health care due to cost concerns.”

The study, published in Health Affairs, found that when compared to Texas, enrollees in Kentucky and Arkansas reported "substantially" better health, fewer emergency-room visits, increased access to care and medications, and cost savings.

                                                        graphic from report 

Kentucky has 1.4 million people on Medicaid, with 470,000 of them covered through the expansion. As of Jan. 1, Arkansas had 310,951 low-income people enrolled on its "private option" plan funded by Medicaid.

Not surprisingly, low-income adults in Arkansas and Kentucky were much more likely to have health coverage than their counterparts in Texas. Researchers found that by the end of 2016, the percentage of people in Arkansas and Kentucky without coverage had dropped 20 percentage points more than in Texas. In 2016, the uninsured rates were 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas.

The study found that low-income adults who had gained coverage in Arkansas and Kentucky under the ACA had:

• A 41-percentage-point increase in having a usual source of health care
• A 58.6-point drop in reports of trouble paying medical bills
• A 74.7-point decline in skipping needed health care because of costs
• A 28-point drop in the likelihood of having an emergency-room visit
• A 23-point increase in the share who reported they were in excellent health
• $337 less in medical out-of-pocket spending per year

It found similar results among low-income adults with chronic illnesses who had gained coverage under the ACA, including:

• 56 percentage points more likely to report having regular care for their chronic condition than were chronically ill adults in Texas
• 51 points less likely than those in Texas to skip medications due to cost
• 20 points more likely to report being in excellent health

The study was conducted by the Harvard T.H. Chan School of Public Health. It surveyed a random sample of 10,885 adults aged 19 to 64 in November and December from 2013 to 2016 via land lines and cell phones. The study includes a demographic breakdown of the full samples in each state.

“This study, along with others, makes it clear that the Affordable Care Act’s Medicaid expansion has helped states make substantial gains in coverage while ensuring people can get and afford the health care they need,” said Dr. David Blumenthal, president of The Commonwealth Fund, which funded the study. “Repeal efforts that end the expansion threaten the health and financial security of the 12 million people nationwide who benefited from it. We must hold on to these gains and continue to work toward affordable and accessible health care for everyone.”

The House-passed health bill, called the American Health Care Act, would largely phase out the Medicaid expansion and limit federal funding of the program, reducing federal spending on it by an estimated 24 percent over 10 years. If people enrolled in the expansion went off it, they could not get back on. About 30,000 Kentuckians a month go on and off Medicaid.

Gov. Matt Bevin has said Kentucky can't afford to pay for its share of the expansion costs (5 percent this year, rising to the ACA's 10 percent limit in 2020) and has applied for a waiver that would let the state charge small, income-based premiums and would require "able-bodied" recipients to either work, volunteer, go to class or take job training, among other things.

The waiver request estimates that the changes would make the state's Medicaid rolls have 86,000 fewer people in five years than without the waiver. The waiver is expected to be approved in June and to go into effect Jan. 1.

House health-care draft suggests a plan that could leave rural areas short of coverage

A 100-page draft of a House Republican plan to repeal the Patient Protection and Affordable Care Act suggests that rural, middle-class Americans may soon struggle to afford health insurance.

The document, which was leaked to Politico last week, specifies that Medicaid expansion for low-income, able-bodied adults won’t be completely eliminated, but eligibility and funding will be rolled back after 2020, Vann R. Newkirk II reports for The Atlantic.

"The draft also contains a provision changing federal funding for Medicaid in 2020 onward from an open-ended obligation to a system where the per-person spending every year is capped based on spending levels in 2019 and increased annually to correspond with medical inflation," he writes.

Then-Gov. Steve Beshear expanded Medicaid under the law, to people with household income up to 138 percent of the federal poverty level, now $16,394 for an individual or $33,534 for a family of four. Now the state is having to pay 5 to 10 percent of the cost, and Gov. Matt Bevin says the state can't afford it. He has asked for permission to change the program, but what Congress does with the program nationally would likely override action in Kentucky.

Rural residents, who rely more heavily on public insurance than do city-dwellers, are particularly vulnerable to Medicaid cuts. The health issues that are prevalent in rural areas are serious and contribute greatly to the climbing mortality among middle and lower class white Americans, he notes. "People like coal miners in Trump country in Kentucky and West Virginia are on the frontiers of several developing health crises, and per-capita spending caps on Medicaid would only further limit their states’ ability to respond," Newkirk writes.

The draft plan by House Republicans repeals the tax-based individual mandate to have health insurance and replaces it with an incentive to maintain continuous coverage. This proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months and who purchase insurance on individual, small group, or exchange markets, Newkirk says. The fee would also apply to young adults who don't enroll in coverage as soon as they age out of their parents' plans. In addition, the added surcharge would be paid as profits to insurers rather than being remitted as taxes to sustain the system, he writes.

Another reform set forth in the draft is a measure to replace the cost-sharing reductions and premium tax credit subsidies of the ACA's exchanges with a refundable tax credit. The existing tax credit is adjusted by income, age, and the average price of insurance in a person's market. The draft version of the tax credit would only take into account age, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60, Newkirk notes.

While older people who are likely to have more health problems would get more subsidy than "young invincibles," Newkirk writes, the worry is that adequate medical care will be out of reach for lower-income people who are also more likely to have health problems. Geographical factors are also likely to become an issue for a tax credit based solely on age, since medical costs vary substantially from place to place.

A tax-credit plan that doesn’t account for the actual cost of a person’s health insurance might reasonably be expected to create areas where coverage is simply unaffordable, Newkirk notes. Research suggests that health-insurance premiums are higher for rural counties and states.

Newkirk writes, "Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers. . . . The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states’ ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them," Newkirk writes.

Newkirk says that disparity between costs and access for rural Americans creates a conundrum for Republicans. "By reducing state Medicaid financial flexibility, reducing oversight over minimum insurance requirements, instilling continuous coverage requirements, and removing regional costs offsets, their Obamacare replacement would in essence put health insurance even further out of reach for sicker, rural patients who need it more and then penalize them for being left out," he writes.

Many rural Americans already suffer the effects of “health care deserts” because of collapsing rural hospital systems and waning access to basic specialty services. In addition to those health care and service deserts in rural areas, Newkirk writes, Republicans would be contributing to newfound “coverage deserts.”