Candidates for governor fuss over credit for opioid settlements

Gov. Andy Beshear and Attorney General Daniel Cameron in
December 2019, after Beshear appointed Cameron to fill his
unexpired term as AG (Associated Press photo by Bruce Schreiner)

By Aneri Pattani
KFF Health News

Opioid settlement cash is not inherently political. It’s not the result of a law passed by Congress nor an edit to the state budget. It’s not taxpayer money. Rather, it’s coming from health-care companies that were sued for fueling the opioid crisis with prescription painkillers.

But like most dollars meant to address public health crises, settlement cash has nonetheless turned into a political issue.

Gubernatorial candidates in Kentucky and other states are clashing over bragging rights for the funds — which total more than $50 billion and are being distributed to state and local governments over nearly two decades. Kentucky's share of the pie is $842 million.

Among the candidates are curremt or former attorneys general who pursued the lawsuits that produced the payouts. And they’re eager to remind the public who brought home the bacon.

“Scoring money for your constituency almost always plays well,” said Stephen Voss, an associate professor of political science at the University of Kentucky. It “is a lot more compelling and unifying a political argument than taking a position on something like abortion,” for which you risk alienating someone no matter what you say.”

Attorney General Daniel Cameron, the Republican candidate for governor, wants sole credit for the hundreds of millions of dollars his state is receiving to fight the opioid epidemic. In a post on X, formerly known as Twitter, he wrote that his opponent, former attorney general and Democratic Gov. Andy Beshear, “filed a lot of lawsuits during his time [in] office, but in this race, there is only one person who has actually delivered dollars to fight the opioid epidemic, and it’s not him.”

Beshear filed nine opioid lawsuits during his tenure as attorney general, several of which led to the current payouts. At a January news conference, Beshear defended his role: “That’s where these dollars are coming from — cases that I filed, and I personally argued many of them in court.”

Christine Minhee, founder of OpioidSettlementTracker.com, who is closely following how attorneys general handle opioid-settlement money, said voters likely don’t know that the settlements are national deals crafted by a coalition of attorneys general and private lawyers. So when one candidate claims credit for the money, his constituents may believe “he’s the sole hero in all of this.”

Candidates in other states are touting their settlement credentials, too. North Carolina Attorney General Josh Stein, a Democrat, lists securing opioid settlement funds at the top of the “accomplishments” section of his 2024 gubernatorial campaign website. West Virginia Attorney General Patrick Morrisey, a Republican gubernatorial candidate for 2024, has repeatedly boasted of securing the “highest per capita settlements in the nation” in news conferences and on social media and his campaign website.

Louisiana Attorney General Jeff Landry, a Republican who was recently elected governor, ran on a tough-on-crime platform, with endorsements from sheriffs and prosecutors. As attorney general, he led negotiations on dividing opioid settlement funds within the state, resulting in an agreement to send 80% to parish governments and 20% to sheriffs’ departments — the largest direct allocation to law enforcement in the nation.

In Kentucky, half the settlement money is being distributed among cities and counties, and the other half is controlled by the Opioid Abatement Advisory Commission, staffed by Cameron's office.

It’s a common joke that AG stands for “aspiring governor,” and officials in that role often use big legal cases to advance their political careers. Research shows that attorneys general who participate in multistate litigation — like that which led to the opioid settlements and the tobacco settlement before it — are more likely to run for governor or senator.

But for some advocates and people personally affected by the opioid epidemic, this injection of politics raises concerns about how settlement dollars are being spent, who is making the decisions, and whether the money will truly address the public health crisis. Last year, more than 100,000 Americans died of drug overdoses.

Average people “don’t really care about the bragging rights as much as they care about the ability to use that funding to improve and save lives,” said Shameka Parrish-Wright, director of Vocies of Community Activists and Leaders (VOCAL-KY), a Louisville-based advocacy group that champions investments in housing and health care.

“What I see in my state is a lot of press conferences and news pieces,” said Parrish-Wright, a Democrat who is active in local politics. “But what plays out doesn’t get to the people” — especially those deeply affected by addiction.

For example, when Beshear celebrated a decrease in the state’s overdose deaths, his announcement overlooked the increasing deaths among Black Kentuckians, Parrish-Wright said.

And when the Cameron aide who chairs the opioid commission proposed that 5% of settlement funds be used to research ibogaine — an illegal psychedelic drug that has shown potential to treat addiction — to help get it approved by the Food and Drug Administration, Parrish-Wright said her first thought was “most poor people can’t afford that.” A recent witness before the commission said the FDA is unlikely to approve it, and even iof it did, treatment should occur only in hospitals because of the risk of heart damage.

The ibogaine announcement caused additional controversy. It’s an experimental drug, and, if approved, the $42 million allocation would be the single-largest investment from the commission. The Daily Beast reported that a billionaire Republican donor backing Cameron’s gubernatorial campaign stands to reap massive profits from the drug’s development.

Neither Cameron’s office nor his campaign responded to requests for comment for this story.

Beshear’s office declined an interview request but referred KFF Health News to his previous public statements, in which he criticized the potential investment in ibogaine. He has suggested that Cameron, whose campaign has emphasized support for police, is not putting his money where his mouth is.

“If you only provide $1 million to law enforcement and 42 [million] to pharma, it doesn’t seem like you’re backing the blue. It seems like you’re backing Big Pharma,” Beshear said at a May news conference.

Minhee, founder of OpioidSettlementTracker.com, said she’s concerned that mixing politics with settlement funds could result in ineffective investments nationwide.

“If some of this money is going to be politicized to advance careers of attorneys general who support the war on drugs, then that is literally using monies won by death to feed into more death,” she said.

Parrish-Wright said she worries that candidates — and some voters — will forget about the significance of the money once ballots are cast. “We cannot let it fade after the election cycle,” she said.

Her solution depends in part on politics. She’s on the ballot herself Nov. 7, for a seat on Louisville’s Metro Council. If she wins, she said, she intends to keep the settlement in the public conversation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of the Kaiser Family Foundation, an independent source of health policy research, polling and journalism.

Kentucky's transgender youth are caught in the middle as Beshear, Cameron and political allies spar over trans health care

Students protested at the state Capitol against a law that banned gender-
affirming care for minors. (Kentucky Lantern photo by McKenna Horsley)

By McKenna Horsley
Kentucky Lantern

Ysa Leon is questioning their future in Kentucky. The outcome of the state's gubernatorial election this November will be a deciding factor.

“I’ve told my family: Be prepared in November, because that might change where I’m staying after I graduate in May,” said Leon, a 20-year-old nonbinary student at Transylvania University, where they are president of the Student Government Association.

Leon and other transgender Kentuckians have been concerned for much of the year as Kentucky politics filled with heated discourse on the rights of trans people, specifically over what gender-affirming medical care for youth should be permitted in the state.

After the General Assembly passed one of the strongest anti-trans bills in the country, Senate Bill 150, Ray Loux, 17, decided to enroll in Fayette County Public Schools’ Middle College program for his senior year. He did not want to worry about which bathroom he should use, what pronouns his teachers will use and “not being able to talk about who I am with my friends in school.”

Ray is considering going to a college out of state.

“I had a panic attack the other day because I wasn’t sure what my health-care situation would look like going forward,” Ray said, noting that he must taper off his hormones while he is underage.

Now, the issue of trans rights has reached the governor’s race.

Democratic Gov. Andy Beshear, who is seeking a second term in office, has released a 15-second ad called ‘Parents.” It focuses on claims made by Republicans, including his opponent Republican Attorney General Daniel Cameron, that the governor supports “sex change surgery and drugs” for kids.

Wearing basic dad attire — a blue button down under a red quarter-zip pullover — Beshear stares into the camera and says: “My faith guides me as a governor and as a dad.”

He then repeats a familiar line — “all children are children of God” — before saying Cameron’s attacks are not true, adding: “I’ve never supported gender reassignment surgery for kids – and those procedures don’t happen here in Kentucky.”

GOP backlash was swift, and rhetoric uplifting culture wars reached the annual Fancy Farm Picnic in West Kentucky earlier this month. Among his jokes for the day, Cameron riffed that come November Beshear’s pronouns will be “‘has’ and ‘been’,” and criticized the governor for protecting “transgender surgeries for kids.” (Those two words are not pronouns.)

In a press conference last week, Cameron highlighted a letter from a University of Kentucky health clinic, stating it had performed “a small number of non-genital gender reassignment surgeries on minors who are almost adult,” but stopped after the ban on gender-affirming medical care for youth took effect.

Hours later, Beshear said in his press conference that the letter was new to him, and said that if a bill that only banned gender-reassignment surgeries for minors made its way to his desk, he would have signed it.

“Daniel Cameron’s taken this race to the gutter in a way that I’ve never seen,” Beshear said. “I mean, right now, I think if you ask him about climate change, he’ll say it’s caused by children and gender reassignment surgeries.”

As politicians put a spotlight on gender-affirming medical care, advocates say the lives of transgender Kentuckians — especially those of the commonwealth’s trans youth — are on the line.

 
‘It’s hard to be a trans child anywhere’

Transgender youth are already vulnerable, and the way politicians talk about trans people in general is “really dehumanizing,” said Oliver Hall, trans-health director at the Kentucky Health Justice Network. They work directly with transgender youth, a demographic that Hall said is being used as a “political football.”

“It’s hard to be a kid. It’s hard to be a teenager in general,” Hall said. “And then it’s additionally hard to be a trans teenager. It’s hard to be a trans child anywhere.”

Leon, who came out as queer in 2020 and then as trans and nonbinary in 2021, said it took a lot of therapy to find themselves. At first, only their roommates and close friends referred to them with they/them pronouns in private.

“When I heard it the first time, I felt like I took the biggest breath ever — this exhale that I’d been holding in for so long. All of this pent up anxiety was gone and I felt so good,” Leon said. “And it’s not that that fixed everything for me, but accepting yourself and having other people accept you changed my life. It changes everything for some people.”

SB 150 took effect in July despite a legal challenge brought by the American Civil Liberties Union of Kentucky. Cameron's office is defending the law, which bans gender-affirming medical care for anyone under 18, including forcing those already taking puberty blockers to stop. It allows teachers to ignore trans kids' choices of names and pronouns, regulates which school bathrooms kids can use, and limits the sex education students can receive.

Beshear vetoed the legislation, but the Republican supermajority in the General Assembly easily overrode it. In his rejection of the bill, Beshear wrote that he was doing so based on the rights of parents to make decisions about how their child is treated and that the law would allow government interference in medical care.

“Improving access to gender-affirming care is an important means of improving health outcomes for the transgender population,” the governor wrote in his veto message.

Leon said gender-affirming care is different for each transgender person. They did not use puberty blockers because they came out as an adult, but socially transitioned with support from their friends and family. Gender-affirming medical care is also not always covered by health-insurance companies.

Having such laws on Kentucky’s books mixed with support from politicians running for the highest state office in the Commonwealth has “a detrimental effect on the physical and mental health of trans people,” said Hall, of the Kentucky Health Justice Network.

Some in the trans community fear that, eventually, gender-affirming care for adults could be banned as well, said Ray’s mother, Shavahn Loux. While her son is in a “better situation than a lot of kids” because he will be an adult in a few months and could regain access to health care, she said “it’s scary” to think Ray’s access to hormone treatment in general could end completely.

“I know a number of people who were thinking about coming here and are now no longer considering it because of this,” she said. “That’s true for trans individuals and non-trans individuals.”

Cameron, asked recently if he thought gender-affirming medical care for adults should be banned in Kentucky, told reporters that he supported “what our legislature did in protecting our children.”

“Adults can make different decisions but this is about protecting kids and making sure that we don’t rob them of youth and innocence,” Cameron said.

‘The right buzzwords’

After a federal judge reversed a temporary block on the health-care part of the new law, Cameron issued a statement calling the treatments “experimental” and vowed that his office would continue to “stand up for the right of children to be children, free from the influences of leftist activists and radical gender ideology.”

Rebecca Blankenship, the executive director of Ban Conversion Therapy Kentucky and the first openly transgender person ever elected to public office in the state, noted that Cameron’s defense was initially “rebuked” by the judge in the injunction, who noted that the drugs “have a long history of safe use in minors for various conditions.”

This shows, she said, that “Attorney General Cameron is willing not only to lie to voters, but even to the courts to advance these political talking points.”

Alexander Griggs, the community outreach coordinator for the Fairness Campaign, said such messaging argues that “Trans people shouldn’t have autonomy over the decisions they make over their bodies” and that their medical needs are “wrong.” With that constant messaging, transgender youth may internalize it, Griggs said: “The more of that language that’s used, the more damage is being done.”

Leon agreed, saying “People think they can say whatever they want, and not realize the harm that it does.”

As a teenager, Leon said they tried their best to fit in with their cisgender peers. They turned to their church, but were presented with the option of conversion therapy, which seeks to change a person’s sexual or gender identity. They rejected the offer, which leading medical and mental-health organizations have criticized.

Leon said, “My mental health and my self-love improved more than I could have ever imagined after I came out as nonbinary.”

Beshear has taken a more moderate stance on gender-affirming medical care. Bobbie Glass, a transgender woman who testified before lawmakers against Senate Bill 150, said Beshear’s recent ad used “very specific” language to discuss his position, pointing out that he did not discuss his position on puberty blockers.

Beshear is using “the right buzzwords” that people in the transgender community will understand, she said, adding that people who don’t understand the terms could interpret the ad to mean “he believes the same thing” they do.

“But then, Daniel Cameron’s going to turn around and try to exploit that stuff with the language he used in his veto,” Glass said. “And so it’s still going to have the effect of just making life miserable.”

Blankenship appreciates Beshear’s ad for “advancing the conversation, in that he’s lowering the temperature of it, and focusing on the truth.” Ban Conversion Therapy Kentucky does not endorse or oppose political candidates.

“He has been unwilling to bow to pressure from radicals to hurt us,” Blankenship said of the governor. “But at the same time, it’s difficult to point to anything that he’s done since maybe 2020, that was clearly designed to help LGBT people.”

Members of the LGBTQ+ community have asked the governor’s administration to direct the state Cabinet for Health and Family Services to track suicides within the community or where conversion therapy is happening in the state, Blankenship added.

The Trevor Project, which aims to prevent suicide among LGBTQ+ youth, reported in 2022 that 59% of Kentucky’s transgender and non-binary kids considered suicide, and 24% tried to take their own lives.

At least 15 laws banning gender-affirming care for transgender youth have been enacted across the country, according to the Human Rights Campaign, along with at least seven laws that require or allow the misgendering of transgender students. HRC also found that more than 220 bills specifically targeting transgender and non-binary people were introduced in state legislatures this year.

If Beshear is re-elected, Hall hopes the governor “will acknowledge the support that trans Kentuckians have given him” and enact executive orders to ensure policies like anti-discrimination protections for transgender people statewide.

Ray called Beshear’s first term “empowering” for trans Kentuckians: “It was really nice to be able to see somebody in a position of power in Kentucky who was accepting of people like me and welcoming of us and embracing us to live in this state.”

A February Mason-Dixon poll released by the Fairness Campaign showed 71% of Kentucky registered voters don’t want lawmakers making the decisions about transgender youths' health care. 

Nevertheless, the Trevor Project’s 2023 U.S. National Survey on the Mental Health of LGBTQ Young People found that 27% of transgender and nonbinary touth reported being physically threatened or harmed in the previous year because of their gender identity.

But the politicization of the issue “is radicalizing people, and people are treating trans people even worse than we have been treated historically,” Hall said.

Leon and Ray say the outcome of the November election will impact their future in Kentucky. Ray is prepared to leave the state for college if he has to. “If Beshear loses, I think Kentucky is going to become a lot less welcoming of a place,” he said.

Leon hasn’t decided: “I’m kind of weighing: Do I stay here and fight for people like me and make it a better state for people like me or do I protect myself and go somewhere where I am safe?”

New coronavirus restrictions will include bars and restaurants; Tuesday is deadliest day for confirmed covid-19 deaths, with 33

State animation shows infection-rate growth from green to red zones.

By Lisa Gillespie

Kentucky Health News

Gov. Andy Beshear said he will impose new pandemic restrictions Wednesday, including limits on restaurants and bars. Meanwhile, coronavirus cases are running so high that health departments are asking Kentuckians who have tested positive for it to do their own contact tracing: notify people they may have exposed to the virus.

Beshear said at his daily briefing, "We will be announcing new steps that we're going to take in this commonwealth. It is time to get control of this beast. I refuse to stand by and watch avoidable loss around us. And we're at war, and there are some right now who want to surrender and accept the fatalities. I'm not that type of governor." 

Beshear announced 2,931 new cases of the virus on Tuesday, the third highest day yet, bringing the seven-day rolling average to 2,487, based on initial, unadjusted daily reports. The highest days were Friday and Saturday, with 3,173 and 3,303, respectively.

The governor also announced 33 more deaths from covid-19, ranging in age from 36 to 99, which he noted was "the deadliest day that we’ve had in our fight against this virus." 

The share of Kentuckians testing positive for the virus in the past seven days also continues to rise. It was 9.1% today, the highest its been since testing became widely available in May. Beshear called this range "dangerous territory," noting that anything above 5% is cause for worry. 

He announced that 1,521 people are hospitalized in Kentucky with covid-19, an increase of 79 from yesterday; 354 of them in intensive care and 178 of those are on a ventilator. 

Beshear reiterated that his new restrictions will be more focused than they were in the spring, partly because testing and personal protective equipment are more available.

“It is not going to look like March, when we had to do 'Healthy at Home’,” he said. when all non-life sustaining businesses closed to in-person services. “So this will be more targeted. But, we've got to stop this. So we’re going to do enough to stop it.”

The Democratic governor said he would talk Wednesday with leaders of the Republican-controlled legislature and industries that will be affected by the new restrictions, before announcing them at his 4 p.m. briefing. It will be his first such briefing for legislators, who have complained about his lack of consultation.

“When these steps come out, we want them to work, and so we'll need leadership on all levels to help us to make that happen,” Beshear said. “And we think taking this extra time to get additional buy-in, can hopefully get us more effective results, and also to communicate especially to those that that may feel the brunt of some new steps.”

Beshear again offered few details on what he said would be mandates and not restrictions, but when asked, he said a statewide 10 p.m. curfew like Ohio's would not be among them. He added that the state would provide assistance for those who would be affected most by the new rules, such as restaurants and bars.

He added that the latest White House Coronavirus Task Force report supports more restrictions, commended his "active measures" and called the spread of the virus "aggressive" and "unrelenting."

“The house is on fire at this point,” Beshear said. “And we need everybody not to close their eyes, close their ears and sit in the house while it burns down on them. We need everybody to join the bucket brigade and to do what it takes to address the crisis.”

State Department for Public Health chart

In a major change, the state will no longer attempt to notify Kentuckians if they’ve been in contact with someone who’s tested positive for the virus. 

“At this point, it is becoming impossible for our local health departments to call each and every one of these contacts in a timely fashion, which is necessary for contact tracing to be effective,” Franklin County Health Department Director Judy Mattingly said in a short video. 

The state is asking people who test positive to reach out to their own contacts if they were within six feet of them for at least 15 minutes in the 48 hours before the test or before their symptoms began.

Health Commissioner Steven Stack said health departments will now focus on identifying new positive cases and enlisting their support to notify their contacts, because the case numbers are so high that the more than 900 people hired by the state to trace contacts can't keep up with the demand. 

“I think that should be no small sign of the situation we find ourselves in,” said Stack, who is a physician.

Stack showed several graphs and charts that showed the number of deaths and cases in Kentucky since March. He showed how the first surge was shut down by the state's Healthy at Home program and the second by the mask mandate. Then he pointed to the current escalation, noting it has a significantly steeper rate of increase than the first two.

“This is where we find ourselves now. This is terrifying. This is now growth from a much higher starting place. The numbers show no signs of relenting,” he said. “There has to be a third intervention.”

Pikeville Medical Center CEO Donovan Blackburn also spoke in a video in the briefing, and said his hospital, like others in the state and region, is nearly full. 

“It is becoming increasingly difficult to accept additional covid patients, especially in our ICU,” Blackburn said. “Transferring patients outside of the region would be our next option; we also are at risk of shutting down other vital services. . . . I urge all Kentuckians to please take this seriously. ”

Blackburn urged Kentuckians to get a flu shot, wear a mask and social distance.

Beshear also made his first public hint that he may seek re-election in 2023, as he said Kentuckians need to wear a mask not for him, but for other Kentuckians.

Holding a hand to his chest, he said, “I hope something touches your heart in a way that it says, ‘Okay, even with all the questions I have or concerns or anger over other things, I'm going to do this, I'm going to put on a mask, I'm going to do what it takes,’ Stay angry with me, vote against me the next time around. At the moment, all I care about is that we get through this, we get through it together and we save as many lives along the line.”

In other coronavirus news Tuesday:

• The 33 fatalities were an 85-year-old man from Barren County; a 69-year-old man from Breathitt County; a 60-year-old man from Calloway County; a 36-year-old woman from Christian County; four women, 83, 90, 91 and 91, from Daviess County; an 89-year-old man from Floyd County; a 51-year-old man from Grayson County; a 78-year-old woman from Green County; an 85-year-old man from Hancock County; a 93-year-old woman from Henderson County; three women, ages 75, 78 and 93, and five men, 49, 79, 87, 88 and 94, from Jefferson County; two men, ages 68 and 72, from Jessamine County; a 94-year-old woman and an 89-year-old man from Madison County; two women, 92 and 94, from McLean County; an 86-year-old woman from Monroe County; a 68-year-old woman and a 74-year-old man from Ohio County; a 65-year-old man from Oldham County; a 99-year-old woman from Rockcastle County; and a 58-year-old woman from Trigg County.
• Counties with 10 or more cases were Jefferson, 330; Fayette, 233; Madison, 156; Daviess, 93; Boone and Hardin, 84 each ; Kenton, 83; Warren, 63; Bullitt, 61; Pike, 58; Laurel, 55; Graves, 52; Campbell and McCracken, 51 each; Barren, 48; Christian, 47; Lee and Nelson, 44 each; Floyd, 43; Calloway, 38; Jessamine, 36; Greenup, 35; Pulaski and Scott, 33 each; Breckinridge, Hopkins and Rowan, 32 each; Henderson, 22; Lincoln, Logan and Muhlenberg, 21 each; Adair, Bell, Boyd, Edmonson and Johnson, 20 each; Marion and Whitley, 19 each; Elliott, Garrard, Grayson, Magoffin, Ohio, Perry, Powell and Wayne, 18 each; Anderson, Boyle, Monroe and Oldham, 17 each; Franklin, Marshall, Mercer and Webster, 16 each; Grant, Hancock and Martin, 15 each; Knox, 14; Green, Lawrence, Shelby and Taylor, 13 each; Casey, Estill, McLean, Meade, Pendleton and Woodford, 12 each; Breathitt, Morgan and Union, 11 each; Clark, Clay, Clinton, Jackson and Mason, 10 each.
• Of today's new cases, Beshear said 325 were age 18 or younger. 
• The state's long-term care facilities have 1,667 active resident cases and 1,015 active staff cases, with 58 new resident and 78 new staff cases reported today. There have been 1,089 resident deaths and six staff deaths attributed to covid-19, with 40 confirmed today.
• The K-12 dashboard shows that last week, 1,063 more students and 567 more staff tested positive for the virus, and 6,557 students and 1,148 staff were in quarantine.
• The college and university report shows 733 students and 10 staff tested positive in the past 14 days, with 66 of the students reported today.  
• Other states are imposing restrictions as the virus surges. California Gov. Gavin Newsom said he was pulling an “emergency brake” and putting almost all counties in the state's most restrictive level. Newsom is a Democrat. Republican Gov. Kim Reynolds of Iowa announced, after months of resisting the idea, that everyone age 2 and older must wear a face covering in indoor spaces open to the public. In Oklahoma, Republican Gov. Kevin Stitt said bars and restaurants must close by 11 p.m., except for to-go and drive-thru orders, and required state employees to wear masks at work.
• Governors of Kentucky, Indiana, Ohio, Michigan, Illinois, Minnesota and Wisconsin sent out a message of unity in the hopes of thwarting the spread of the surging virus, with a shared concern about the stress this surge is placing on their hospitals and staff, Travis Ragsdale reports for WDRB. 
• Friendship Health and Rehab in Pewee Valley asked for help from the state's nursing strike team after 63 residents and 20 staff tested positive for the virus, WDRB reports. Six residents of the 142-bed facility have died from covid-19 since the pandemic began.  
• At a weekly news conference, three of the largest hospital systems in Louisville said they are able to handle the increase in covid-19 patients right now," Lexie Ratterman reports for WDRB. But Dr. Jason Smith with U of L Health warned, "There will always be a breaking point. I think we are doing a good job across the three healthcare systems in managing this right now, but sooner or later if the numbers continue to rise, it's a simple matter of numbers, in that you will eventually overwhelm the healthcare system no matter how well prepared and how much they're working."
• A father-son team of infectious-disease doctors add their voices to others who are asking Kentuckians to scale back or to cancel their Thanksgiving plans, Jeremy Chisenhall reports for the Lexington Herald-Leader. Dr. Mark Dougherty and his son, Dr. David Dougherty, told Chisenhall that "it’s vital that older and at-risk populations remain aware of covid dangers and stay safe – even if it means declining an invitation to the family dinner this year." Mark Dougherty said, "If younger people are not going to protect the vulnerable and elderly, then the vulnerable and elderly need to protect themselves." 
• Health departments across Eastern Kentucky released new coronavirus numbers, including one new death, on Tuesday and WYMT reports on them. 
• WYMT reports about the outbreak of coronavirus cases at the Lee Adjustment Center in Beattyville, which has seen more than 430 inmates and nearly 30 staff test positive in the 866-bed facility. 
• The Centers for Disease Control and Prevention has removed from its website a statement that stressed "the importance of reopening America's schools" in the pandemic. "The now-withdrawn statement, which took a stronger tone in favor of reopening than the agency's other guidance documents, was reportedly influenced by White House discussions over the subject," Education Week reports. "It appears to have been removed on Oct. 28, according to cached versions of the website kept by the Internet Archive.

As big surge in covid-19 cases begins, along with warm weather, Beshear warns gatherings will kill Kentuckians; vows enforcement

Gov. Andy Beshear spoke in his daily press conference as information sources were displayed.

By Al Cross
Kentucky Health News

As he reported a big surge in daily cases of the covid-19 disease caused by the coronavirus, and reports of gatherings that could spread it, Gov. Andy Beshear gave perhaps his most extended oration about the need for Kentuckians to restrict their activities to keep the virus from spreading.

"I know the personal emotions that this coronavirus is causing. It makes us anxious, afraid, uncertain, sad and isolated; but I hope you know that I think right now we are more connected than ever, even if we have to be physically apart," Beshear said near the start of his daily press conference.

"Our safety depends on us caring about each other, more now than ever before in my lifetime," he said. "It requires us being a commonwealth for the common good, putting the health of our people above our self-interests. In fact, it is a calling for us to hear, and a clear truth for us to believe, that our individual actions as we move through this impact the safety and the health of others."

Then Beshear alluded to politics, a subject he has tried to avoid in his public comments during the crisis.

"You know, when I was elected last November, I felt we were as fractured and as separated of a commonwealth and as a country as I have ever seen, and I believe now we are more united than I have ever seen, and I believe now that we are more united than I have ever seen," he said.

He added later, "Every single one of us have to live up to our duty as a member of the commonwealth and as a patriotic American, to protect those around us; more than ever we are connected to each other; our actions matter."

Noting a gathering of hundreds of young people in Louisville Friday night, and funerals open to more than immediate families, he said, "If hundreds of people come together, several people are going to die because of it; that is what we are facing. We’re getting reports of funerals that are not limiting the number of people. That loved one that’s passed on would not want their funeral to be a reason that someone else has passed on."

Beshear has issued an emergency order banning "all mass gatherings," but violations of that appear to have increased with warm weather. "There are going to be people out there asking you to break up if you are in these groups," he said. "If you come together in a large group, probably multiple people are going to die because of it."

The state reported 92 more cases of covid-19 Saturday, by far the largest in any one day. The previous high, 54, was the day before. "We are seeing at least the start of our surge, and we know know more than ever that we have to engage in social distancing and we have to do our duty as a Kentuckian and an American. Those things that divided us three months ago don’t matter."

Federal appeals court strikes down Medicaid work requirements

Gov. Matt Bevin announced his plan in 2016. (WFPL photo)

A federal appeals court ruled Friday against the work requirements that then-Gov. Matt Bevin tried to impose on Medicaid enrollees who were not "medically frail" and had no dependents.

The Trump administration was arbitrary and capricious when it approved Bevin's plan and one in Arkansas, a three-judge panel of the U.S. Court of Appeals for the District of Columbia Circuit ruled unanimously.

The U.S. Department for Health and Human Services essentially ignored the main purpose of Medicaid, which “was to provide health-care coverage to populations that otherwise could not afford it,” wrote Senior Judge David Sentelle, who was appointed to the court by Ronald Reagan.  The Trump administration is expected to ask the Supreme Court to hear the case.

The ruling upheld several by a judge in the D.C. District Court, which scuttled a program Arkansas had started and kept Kentucky's from taking effect. Democratic Gov. Andy Beshear, who defeated Bevin in the November election, rescinded Kentucky's plan soon after taking office in December. Republicans control the state legislature but have shown no interest in enacting Bevin's plan.

The plan had been challenged by 16 Medicaid beneficiaries in the state, who noted the Bevin administration's initial forecast that Kentucky Medicaid rolls would have 95,000 fewer people in five years than without the plan, in large measure because of noncompliance with the requirements to work, attend school or perform community service 80 hours a month and report monthly.

Rural hospitals will get millions in settlement being negotiated with state, but range of possible amounts is wide; will feds help pay?

Most of Kentucky's rural hospitals are in line for millions of dollars of taxpayer money to settle an old lawsuit with the state, but just how many millions is uncertain. So is whether the federal government will foot part of the bill, reports John Cheves of the Lexington Herald-Leader.

The 58 hospitals "won a series of court rulings finding their Medicaid reimbursement rates unfairly low from 2007 to 2015," Cheves writes. "Last year, a unanimous three-judge panel of the Kentucky Court of Appeals sided with the hospitals. The Cabinet for Health and Family Services erred during the administration of then-Gov. Steve Beshear, the current governor’s father, the appeals court found."

The cabinet has appealed to the state Supreme Court, which hasn't decided whether to take the case and has given the two sides extra time to negotiate a settlement.

State Budget Director John Hicks

After losing to now-Gov. Andy Beshear in November, then-Gov. Matt Bevin sent the legislature a budget memorandum that estimated the cost of the settlement at $426 million. But the budget the Democratic governor proposed to the Republican-controlled legislature estimates it at $61.9 million.

“The 420 was a number that never should have been revealed,” Budget Director John Hicks told the Senate budget committee Feb. 4. “It was some forecast of the prospect of the loss to the Commonwealth, and current events are proving that’s not likely to take place to any extent to 420 million.”

Cheves reports, "An attorney for the majority of the hospitals suing the state said the $420 million estimate depends on whether the federal government, through the U.S. Centers for Medicare and Medicaid Services, agrees to share in the damages alongside the state of Kentucky." Medicaid paid 71 percent of Kentucky Medicaid costs from 2007 to 2015.

Politics could play a role. After Donald Trump was elected president, Bevin and CMS worked to make unrelated changes in the program, but their effort to require work from able-bodied Medicaid beneficiaries was blocked by the courts, and Beshear rescinded it.

Kentucky's rural hospitals began objecting in 2007 to changes in their Medicaid reimbursements. In 2010, the cabinet began holding individual dispute-resolution meetings with them. “Rather than issuing dispute-resolution decisions, the cabinet waited until May 31, 2013, to write the hospitals letters (saying) that they did not have appeal rights and dismissing the same without administrative evidentiary hearings or further due process,” the Court of Appeals said in its decision. “The hospitals requested administrative hearings from the cabinet’s dismissal letters within 30 days pursuant to [state administrative regulations]. The cabinet responded to those requests with letters stating no administrative hearings would be conducted.”

The same day it dismissed the hospitals' complaints, the cabinet sued them, seeking a ruling to uphold its Medicaid reimbursement formula. The hospitals counter-sued, leading to a Franklin Circuit Court ruling and the Court of Appeals decision. "In October 2015," Cheves notes, "the cabinet replaced the Medicaid reimbursement rate methodology that led to the litigation with a new one."

Executive of 'low-rated' nursing-home chain is now health cabinet's inspector general, overseeing nursing-home inspection

Adam Mather

When Andy Beshear became governor a month ago, Adam Mather was regional operations vice president for Signature HealthCare, a Louisville-based firm "that owns more than two dozen low-rated nursing homes around the state," writes John Cheves of the Lexington Herald-Leader. Twenty days later, Mather started work as the Beshear-appointed watchdog of Kentucky’s "troubled nursing home industry" as inspector general of the Cabinet for Health and Family Services.

Mather's office "inspects several hundred nursing homes in Kentucky on behalf of the federal government, which pays for the bulk of residents’ care through Medicare and Medicaid," Cheves notes. "Poor results on inspections can lead to expensive fines and, in extreme cases, loss of federal funding."

"Many Signature nursing homes haven’t been faring well in these inspections," Cheves reports. "A Herald-Leader analysis of 42 Signature facilities in Kentucky shows that 25 are rated as “much below average” or “below average” by the U.S. Centers for Medicare and Medicaid Services five-star rating system, which considers quality of patient care, staffing and health inspections." The average rating for Signature's 42 homes was "below average."

One of the "much below average" homes is Signature HealthCare at Jefferson Place in Louisville, which was fined $140,421 in 2018 "after inspectors cited repeated cases of resident neglect that led to physical injuries and personal humiliation," Cheves reports.

Toby Edelman, senior policy attorney for the Center for Medicare Advocacy in Washington, told Cheves, “It’s troubling that someone from the industry now gets to oversee the industry. I don’t know him personally, so who knows, maybe he’ll turn into a whistle-blower. But generally, I think our regulators should be independent of the industries they regulate and not come from within their ranks. There should not be this revolving door between them, with people moving back and forth. Why not appoint an advocate, someone who cares about the residents and who has a track record of being a little more skeptical of the companies?”

Beshear's office didn't respond to Cheves' request for comment, but acting Health Secretary Eric Friedlander said, “Adam is fully committed to ensuring there is never a conflict of interest and to maintaining absolute integrity within the OIG. The entire OIG team are a vital part of this mission.”

Cheves notes the political activism of the nursing-home industry. A Kentucky Health News search for Signature employees on the Kentucky Registry of Election Finance website found that they gave $500 to his 2015 campaign for attorney general, $6,750 to the 2011 campaign of his father, Gov. Steve Beshear, and $5,000 to the campaign of Republican incumbent Matt Bevin, who lost to Andy Beshear. No contributions to Andy Beshear's gubernatorial campaign were listed.

Is Bevin 'trying to rip health care away from our families'? Is it true Beshear 'sold out Kentucky' in an opioid lawsuit? Here are facts.

Northern Kentucky debate (Photo by Albert Cesare, Cincinnati Enquirer)

By Al Cross
Kentucky Health News

Health-related issues figure prominently in some of the final messages that the candidates for governor are delivering to voters as Tuesday's election approaches.

Democratic Attorney General Andy Beshear says of Republican Gov. Matt Bevin, "He has tried to rip health care away from our families."

A Republican TV commercial says Beshear is "so liberal, he wants to give taxpayer-funded health care to people who can work and choose not to."

And a Bevin TV ad says, "Beshear did profit from opioids" and "sold out Kentucky."

The three commercials have varying degrees of truth, and as usual for political ads, fall far short of telling the whole story. They obscure a fundamental difference between the candidates on an issue that affects hundreds of thousands of Kentuckians.

That is the expansion of the federal-state Medicaid program by Beshear's father, then-Gov. Steve Beshear. At last count, the expansion covered more than 450,000 people, paying their bills when they get health care.

Bevin's proposal

Bevin wants to require as many as half of those people (estimates vary) to work, volunteer, attend school or take job training at least 80 hours a month, and make monthly reports, in order to keep their benefits. Those who are medically frail or must care for children would not be included.

Studies indicate that most Kentuckians who would be affected by the "community engagement" rules are already meeting them. One study based on polling found that 97 percent already meet the requirements; another, based on claims data, showed that 64% are.

A federal judge in Washington, D.C., has blocked Bevin's plan, known as a waiver, and judges who heard an appeal last month sounded skeptical of it. Bevin has issued an order that would abolish the expansion six months after a final court decision against his plan. He has said the Supreme Court will decide the issue; the high court does not have to consider appeals.

The first version of Bevin's plan estimated that after five years, the state's Medicaid program would have 95,000 fewer people than it would without it—largely because of noncompliance, including lack of reporting. "This is paperwork and it is intended to tear health care away from people," Beshear said in a debate, pledging to do away with the plan "in my first week of office."

Bevin "has justified the idea both in terms of cost—because the state pays about 10% of the costs of the expansion—and values," Idrees Kahloon of The Economist magazine writes in a "Democracy in America" column about the governor's race after interviewing Bevin.

"When your correspondent asked him whether the point of the waiver was to save the state money, he flatly answered, 'No,' and then held up both his index fingers, one of which was more curved than the other, the result of having had to set it himself when he was young."

“I have scars on my body that we couldn’t afford to get stitched up so they’re as thick as a finger instead of thin as a string,” Bevin told Kahloon. “Every dollar we give to an able-bodied, working-age person with no disabilities and no dependents is a dollar we’re not able to provide … for those truly in need in our state.” Bevin often says he has empathy for the uninsured because he didn't have health insurance until he joined the Army.

Kahloon, a native of Morehead, notes, "Many of the counties in Kentucky most reliant on Medicaid—both for health coverage and to keep rural hospitals financially solvent—are also steadfastly Republican strongholds. To make inroads with them, Mr. Beshear must instill fear about the prospect of policy change. Whether he has done so is unclear."

State House Minority Leader Rocky Adkins, who ran second in the May primary, talked about Medicaid as he campaigned last week with Beshear in Democratic counties in Eastern Kentucky. In that region, he said, “The only growth we’ve seen here has been in the health-care industry.” Bevin has discounted estimates of the Medicaid expansion's creation of jobs.

Opioid epidemic

There has been less debate about the Medicaid expansion than about Beshear's record on the opioid epidemic. The Bevin ad's contention that Beshear "did profit from opioids" and "sold out Kentucky" are based on Beshear's partnership in the law firm of Stites & Harbison. It represented Purdue Pharma in the lawsuit filed against the maker of Oxycontin by then-Attorney General Greg Stumbo in the mid-2000s.

Stumbo's successor, Jack Conway, settled the case for a $24 million payment by Purdue Pharma shortly before Beshear became attorney general. Beshear has said he took no part in the matter, but has refused to say whether he shared as a partner in the fees the law firm earned from Purdue. After Beshear took office, he approved a retroactive $4 million contract for work on the case by a Louisville firm that later made Conway a partner.

Beshear said in 2017 that he did not "recall doing any work" on the case at Stites & Harbison. "I was there a long time," he said. "I don't want to suggest that no one asked me a question about what General Conway was like or not like, but I was not an active participant in that case."

This year Beshear wrote a memo that "says he stepped away from anything related to the state's litigation against Purdue when he took office," Phillip Bailey reports for the Louisville Courier Journal. "Why write that memo three years later? Beshear made multiple attempts to stiff-arm that question and others when I asked about the memo last week . . . Beshear said it was more appropriate to go through a campaign spokesman to schedule an interview, but he eventually relented."

Beshear told Bailey, "We had a policy from the beginning that I was not involved in any Purdue matter other than making a recommendation about where the settlement funds went," but wanted to document it because Purdue Pharma was rumored to be headed for bankruptcy.

Bevin's chief of staff, Blake Brickman, told Bailey, "The memo only raises further questions. Any competent and ethical attorney knows that recusal letters are put in the record immediately, not over three years after the alleged recusal occurred."

In 2017, Purdue Pharma got Pike Circuit Judge Steven Combs to seal the case file, including the only deposition from a member of the Sackler family that owns the company. Stat, the health-and-science publication of The Boston Globe, asked Combs to unseal the file, and Beshear's office took no position on the issue (after denying an open-records request for the deposition, citing Combs' order). Combs granted Stat's motion, but Purdue has appealed.

As attorney general, Beshear has sued nine opioid manufacturers and distributors, alleging that they caused or worsened the opioid epidemic, which has left thousands of Kentuckians dead from overdoses. He says no other attorney general in the nation has filed as many suits against opioid makers and distributors. Bevin has noted that none of the suits have resulted in settlements.

Bevin and Beshear hotly debate governor's Medicaid work rules, their effect and their cost; and their stands on health insurance

Gov. Bevin and Attorney General Beshear debated Oct. 15. (Photo by Ryan Hermens, Lexington Herald-Leader)

By Melissa Patrick
Kentucky Health News

A key difference between Kentucky's gubernatorial candidates is that one wants to require most able-bodied adults on Medicaid to work or participate in other "community engagement activities" in exchange for their health insurance, while the other says he would immediately dismiss such a proposal if elected because it's designed to kick people off of the Medicaid rolls.

Republican Gov. Matt Bevin and his administration have tried to add such requirements through a waiver of traditional Medicaid rules. It would require, among other things, most of the state's able-bodied adults who gained coverage through the expansion of Medicaid (to people who earn up to 138 percent of the federal poverty line) to work, go to school or take job training 80 hours a month unless they are medically frail or must care for children.

A federal judge in Washington, D.C., has blocked the waiver. On Oct. 11, an appeal was heard by judges who indicated they are unlikely to revive it. Bevin has said he expects the Supreme Court to decide the issue. He has issued an executive order that would end the Medicaid expansion six months after a final ruling against his plan.

The televised debate at the University of Kentucky Oct. 15 was the first time Bevin and Attorney General Andy Beshear had locked horns over this issue and it was a lively exchange.

Bevin said, "I am a strong proponent of able-bodied, working-aged men and women who do not have dependents and have the capability of going to work, to go to work in exchange for that which is provided for them by people who do go to work."

The governor said he has empathy for such people, telling his oft-told story of how he was raised poor and no health insurance until he joined the Army.

"I also know that it is an amazing degree of bigotry that allows people to assume that someone like myself had no opportunity, needed to be babied, needed to be put in a position where I was given things as opposed to opportunity and an expectation that I seize that," he said. 

Bevin said expanded Medicaid should be "available for those who need it and the medically frail and women with children," he said.

Beshear disagreed. After calling health care "a basic human right" he declared that if he was elected Nov. 5 he would drop the waiver, which would require those covered by the community-engagement rules to report their hours monthly and be locked out of the program for non-compliance.

"This is red tape. This is paperwork and it is intended to tear healthcare away from people," Beshear said. "I will always stand up against that, and I'm going to rescind that Medicaid waiver in my first week of office."

Beshear noted that after Arkansas implemented Medicaid work requirements,where 18,000 people lost their coverage before the same judge who got Kentucky's case blocked the program,  "The vast majority of people who lost their coverage were already working," he said.

Harvard University researchers have found that most of those affected by the Arkansas work requirements were already working and likely lost coverage because of a "lack of awareness and confusion about the reporting requirements," Phil Galewitz reports for Kaiser Health News. "They also found that there was no evidence they had either secured jobs or other insurance coverage."

Studies indicate that if appellate courts allow the Kentucky waiver, most who would be affected by its work rules are already meeting them. One study based on polling found that 97% are already meeting the requirements; another, based on claims data, shows 64% are.

Numbers, oversimplified

Beshear added, "Governor Bevin's plan will rip 95,000 people off health care that have it for the very first time and I think that's wrong."

That line had some over-simplifications. Some people on the Medicaid expansion have had health insurance in the past, and the numbers cannot be individualized because tens of thousands of people go on and off Medicaid each month due to changes in their eligibility.

The 95,000 number comes from Bevin's original proposal, which estimated that in five years, Kentucky's Medicaid rolls would have 95,000 fewer people than they would without the waiver. Academic health experts said in a friend-of-the-court brief that a more likely range was 175,000 to 297,500. Medicaid covers 1.4 million Kentuckians, around 450,000 of them under the expansion.

Bevin replied to Beshear, "This isn't about people being, having anything ripped away from them. What I propose is that people work and or volunteer and or go to school or be in training or take care of someone in exchange." Further, he said if a person is already meeting the requirements, as was a person Beshear cited as an example, they have nothing to worry about.

Beshear also noted a recently published report by the General Accounting Office, the investigative arm of Congress, which found that Kentucky has budgeted $272 million in fiscal years 2019 and 2020 to pay for the technology and administrative costs of Bevin's plan, an amount roughly twice the combined expense of four other states that are also working to implement similar requirements.

"And his plan is going to cost $272 million of our taxpayer dollars," Beshear said. He did not note that 87 percent of the money comes from the federal government.

Talking over each other, Bevin pushed back and suggested that  Beshear and "the people who wrote your comments" didn't bother to read the report, saying it would not cost that much.

The report says the budget is based on 620,000 Kentuckians being affected by the new Medicaid requirements, which is a much larger number than has been previously reported but apparently includes people who would qualify for exemptions because of children, frailty or other reasons.

Asked about access to care, Beshear said he would fight to keep "federal health care reform" -- otherwise known as the Affordable Care Act or Obamacare -- and its expansion of Medicaid, which he said is "absolutely critical" to the survival of rural health care and rural hospitals.

"With the current lawsuit that threatens the very future of expanded Medicaid, rural health care is on the line," Beshear said. "Everybody should be able to get the health care coverage they need in their hometowns," he said.

Answering the question about access, Bevin said it is a "form of bigotry" to assume that people can't fend for themselves. "It's easy to say that health care is a right," he said, "but the reality is it's one that costs money."

Requiring insurance for pre-existing conditions

The two candidates also had a noisy discussion about whether Bevin supports taking away  protections for pre-existing conditions.

This stems from his support of association health plans (AHPs), a type of insurance that makes it easier for small employers to band together, free of many of the requirements of the ACA.

Bevin says he doesn't support any plan that denies coverage for pre-existing conditions because the  U.S. Department of Labor clearly says AHPs "may not charge higher premiums or deny coverage to people because of pre-existing conditions."

Beshear says AHPs have loopholes that allow them to deny coverage. For example, AHPs do not have to cover all the essential benefits required by the ACA, such as maternity, mental health or prescription drugs, allowing them to create benefit packages that are of limited use to people with certain health conditions. AHPs are also allowed to vary premiums based on age, gender, industry and geography, which are factors that can be used to predict or anticipate pre-existing conditions.

"You can go to the doctor and learn you have a chronic disease, but it's not covered," Beshear said. "Your kids may get the flu . . . but pediatrics isn't covered. You might get home and find out that you're expecting a child, but maternity is not covered," Beshear said. "This governor supports health care that doesn't cover anybody's basic needs."

Bevin pointed to the Labor Department ruling and said, "These are scare tactics and lies. Nothing I have ever proposed offers any of these things that he is saying. . . .  So everything that you are threatening is not true and the things that you are saying I said are not true."

Pre-existing pool for pre-existing conditions?

Beshear also pointed out that Bevin said we should go back to how pre-existing conditions were treated before federal health reform. To which Bevin said, "I never said that."

Beshear's campaign said he was referring to Bevin's comment that he would support going back to high-risk pools for people with pre-existing conditions, which Kentucky used before the ACA.

Problems with the high-risk pool, called Ky Access, were numerous. It never enrolled more than 4,837 people, cost almost $14,000 a year in 2013 and had a $2 million lifetime cap per enrollee, Lisa Gillespie reported in 2017 for Louisville's WFPL.

"Costs to both the state and individuals rose so much because there weren’t any young, healthy people to balance out all the high medical costs," Gillespie reported. "That’s according to Advocacy Action Network executive director Sheila Schuster. She helped oversee the rollout of KY Access."

“It was essentially a conglomeration of people with high-risk, chronic conditions that were going to be very costly,” Schuster told Gillespie. “The premiums were very high, but it was the only game in town.”

Bevin wants 'inaccurate and defamatory' Democratic ad taken down; Frankfort paper finds it lacks context, but isn't baseless

Gov. Matt Bevin has asked TV stations to take down what his campaign calls a "factually inaccurate and defamatory" commercial that says Bevin has tried to take health care away from children and people with pre-existing conditions.

The Bluegrass Values ad, funded by the Democratic Governors Association, features Hoppy Henton, a Democratic activist fromVersailes, who says Bevin has tried "to take away health-care coverage, including vision and dental, from children" and has sued "in court to take away protection now that people have for preexisting conditions."

Davis Paine, Bevin’s campaign manager, said in a press release, “A look at the facts shows that every claim made in this ad is false,”

However, The State Journal of Frankfort reports, "Several claims made in the ad lack context, but they are not baseless."

The crux of the matter is Bevin's efforts to change Medicaid to require, among other things, "able-bodied" adults who are not primary caregivers to work, attend school, take job training, search for a job or volunteer 80 hours a month, if they don't qualify for an exemption or are in drug treatment. The plan has been blocked twice by a federal judge in Washington, D.C.; his rulings will be considered by three appellate judges on Oct. 11.

After the plan was vacated the first time, the Bevin administration moved to end free dental and vision benefits from about 460,000 Medicaid patients who gained their health insurance through the expansion of Medicaid to those with incomes up to 138 percent of the federal poverty line.

The cuts did not apply to pregnant women or children, but for several weeks in July 2018, "The new system — reportedly through a glitch — also led to multiple children and pregnant women being denied vision and dental care, as reported by several independent news outlets," Emily Laytham writes for The State Journal.

The Bevin administration eventually restored dental and vision benefits to the expansion population, as well as those unintentionally affected by the system glitch.

In its press release, the Bevin campaign does not mention the events of last summer, but cites a November letter from the U.S. Department of Health and Human Services saying: “Beneficiaries receiving state plan benefits will continue to receive covered vision services, dental services, and over-the-counter medications . . . all beneficiaries under 21 years of age receiving services through the demonstration will continue to receive all early and periodic screening, diagnostic, and treatment services.”

The ad also suggests that Bevin is suing to “take away protections … for pre-existing conditions.”

In June, Bevin and 14 other state officials appealed a federal judge's decision that limited access to association health plans, a type of insurance that makes it easier for small employers to band together, free of many of the requirements of the Patient Protection and Affordable Care Act. Such plans are intended to reduce small business owners' cost of providing coverage.

The U.S. Department of Labor says association plans "may not charge higher premiums or deny coverage to people because of pre-existing conditions," but Laytham reports, "Workarounds exist."

According to the American Medical Association, “There is a significant risk that AHPs could disproportionately impact individuals with pre-existing conditions” by charging “based on factors that are not explicitly defined in terms of health or medical conditions, but that closely track those forbidden factors."

The AMA notes that association plans are permitted to vary premiums by age, gender, industry and geography, factors that can be used to predict or anticipate pre-existing conditions.

Bevin’s campaign did not respond to The State Journal's request for comment.

Attorney General Andy Beshear, the Democrat running against Bevin in the Nov. 5 gubernatorial election, says he would immediately rescind Bevin's Medicaid plan if elected.

Deepest study yet finds 64% of Kentuckians who'd be affected by Bevin's proposed Medicaid work rules are meeting them already

By Melissa Patrick
Kentucky Health News

Gov. Matt Bevin says "hundreds of thousands" of able-bodied adult Kentuckians on Medicaid should be working but choose not to. But when his new Medicaid "community engagement" rules were set to kick in last July, only about 48,000 people on the program would have been short of meeting the requirements, according to a study of Medicaid records and a random-sample survey of people on the program.

Bevin made his assertion at a July 12 Kentucky Chamber of Commerce meeting in Louisville while promoting his new Medicaid plan, which, among other things, requires "able-bodied" adults on Medicaid who are not primary caretakers to work, attend school, take job training, search for a job or volunteer 80 hours a month, if they don't qualify for an exemption or are in drug treatment.

The plan, called Kentucky HEALTH, for Helping to Engage and Achieve Long Term Health, was set to start July 1, 2018. Two days before that, and again on April 1, it was blocked by U.S. District Judge James Boasberg of Washington, D.C. He ruled that federal officials failed to show how the requirements would serve the objective of the 1965 Medicaid Act, to provide people with medical coverage. He also struck down a similar plan in Arkansas. The administration of President Donald Trump has appealed the ruling.

The study was done by health researchers at the University of Pennsylvania, whom the state and the Centers for Medicare & Medicaid Services hired to evaluate Kentucky HEALTH if it takes effect. Kristi Putnam, deputy secretary of the state Cabinet for Health and Family Services, said the study was not commissioned by the cabinet, but was done under an agreement in the contract that allows the university to conduct its own research. The study was published in the Journal of the American Medical Association, meaning it underwent review by other experts before publication.

Putnam said the report does not refute the governor's assertion that there are hundreds of thousands of people on Medicaid that should be going to work, but choose not to.

"I would disagree with that on a universal basis," she said. "I think you have to consider the whole picture of those who are not employed in Kentucky, and not just the ones who are not meeting [the requirements for] benefits programs that are at this point theoretical programs. I think you have to take it as a whole."

She added, "We still believe that there are those hundreds of thousands of people," but the way the study represents those individuals "is a little bit difficult to see."

The study findings

The researchers found that when the program was first set to roll out 13 months ago, 330,075 of the nearly 1.4 million Kentuckians on Medicaid would have been required to participate in Kentucky HEALTH in some way: work or other community engagement; reporting of engagement activities; paying income-based premiums; and earning credits to get free dental and vision care.

Of this group, 132,790, or nearly 40 percent, would have been required to meet the community engagement requirements (the only part of the program that the study evaluated). Most of the 132,790 people were already in compliance; 25,422 were excluded because they were medically frail, 57,981 were already working the required 80 hours a month; 727 were volunteering that much; and 235 were doing a sufficient combination of work and volunteering.

That left 48,427 people who were not meeting the proposed community-engagement requirements. That is 36% of those who would have to meet those requirements, 15% of those who would have to meet any of the other new requirements, and 3.5% of the state's total Medicaid population.

Chart shows how estimates were made. Data with blue backgrounds are population counts from claims data; in tan backgrounds are estimates from a survey of 9,396 Medicaid beneficiaries.

The study excluded 101,502 Medicaid beneficiaries who are on the Supplemental Nutrition Assistance Program (formerly known as food stamps) or the Temporary Assistance for Needy Families program, formerly Aid to Families with Dependent Children, or "welfare."

Putnam, the deputy health secretary, said they should be included in the workforce numbers as not working because many are unemployed, under-employed, are medically frail for only a limited amount of time, or could be participating in the job market "at a higher level" than they are now.

"I recognize that the governor's statement was not [about] underemployment, but that is part of the group that we are trying to help through this," she said.

She said the number the cabinet typically uses to represent how many able-bodied individuals on Medicaid could be working is between 150,000 and 200,000, a number that she said varies because tens of thousands of people move in and out of the program each month.

When Bevin used the phrase "hundreds of thousands," his office told Kentucky Health News that the figure came from the Census Bureau's 2017 American Community Survey, a poll that estimated 443,723 Kentuckians "do not have a disability and are not in the labor force."

Dustin Pugel, a policy analyst at the liberal-leaning Kentucky Center for Economic Policy, pointed out that only 136,400 of the 443,723 people Bevin's office cited were eligible for Medicaid, had insurance, were not disabled and were not in the labor force. ""It becomes pretty clear that we are not talking about 443,000 sitting on their couches," he said.

He said the census poll shows that of the 136,400 Medicaid-eligibles who are not in the workforce, 57,800 had related children in their home; 24,600 were enrolled in school; 6,100 received retirement income; 19,000 received Medicare, which means they did not self-attest to a disability, but had a health condition that qualified them for Medicare coverage as a non-senior. He noted that the numbers are estimates rounded to the nearest hundred and have large error margins.

"The point is that there are far fewer than 443,000 Kentuckians covered by Medicaid who are not working, and of those who are covered by Medicaid but outside the labor force, many have good reason to be," he said. "To assume that all of them could or should turn around and 'go get a job' is wrong headed."

The study surveyed a random sample of 9,936 people who would be subject to the new requirements. That produced estimates of the well-being of the 48,427 who were not meeting the community-engagement requirements: 27% reported fair or poor physical health; 25% reported fair or poor mental health; 33% reported that a health condition limited their activities in the previous 30 days;  60% needed medical care in the last six months; 27% went to a hospital emergency department in the last six months; and 17.5% were working, but less than 80 hours a month.

Pugel and Jason Dunn, policy analyst with Kentucky Voices of Health, said the study confirms what other studies have found, but is stronger because it used the survey and Medicaid claims during 2018.

"These studies all seem to come up with the same results," Dunn said. "People are either already working . . .  and then the rest are providing care-taking for an ill or disabled relative or a child, or they are in school full time. There are just very few that meet that narrow population of not doing something, and we don't know why."

Pugel said, "We don't know what those folks situations are, we only know that they are not currently meeting the requirement as it is written."

Bevin and other advocates of the requirements have argued that free medical care discourages people from seeking work because they might lose their eligibility.

Dunn said the study "shows that the work reporting requirement is simply not necessary. That's the main point that we've been trying to get across, that requiring this level of activity for the sake of eligibility is not necessary. . . . It is ultimately going to harm people in the long run by denying them access to care."

The study also found that between 10% and 20% of those subject to the new rules may need to report hours through other means, like phone or mail, since they did not have access to the internet.

It found that the proportion of Medicaid enrollees that were required to meet the community engagement reporting requirement didn't vary by geographic area, despite large differences in economic opportunities across the Kentucky workforce areas.

The Green River region in Western Kentucky, which includes Owensboro, and Kentuckiana Works, which includes Louisville, stood out in the 10 local workforce areas because about 20% of those who would be required to report community engagement hours did not meet the proposed requirements. The rest of the state ranged from 12.6% to 15.6% for this measure.