Robert Slaton dies at 81; was a catalyst for many health projects, including Passport Health Plan and Kentucky Health News

Robert Slaton, Ed.D.

Robert Slaton, a health-care consultant and former Kentucky public-health commissioner who was a catalyst for various health-improvement projects in the state, including Passport Health Plan and Kentucky Health News, died Dec. 27 after suffering a stroke a few days earlier. He was 81 and lived in Louisville.

Slaton, who had master's degrees in education and social work and a doctorate in education administration, was state health commissioner in 1978-79, then ran the Public Service Institute at Kentucky State University and was external-affairs administrator for Trover Clinic, now Baptist Health Deaconness Madisonville, his hometown, from 1983 to 1989. While at the University of Louisville, he was Gov. Brereton Jones' special assistant for health-care reform, executive director of the university's primary-care center, executive director of the Medical School Practice Association and executive vice president of University Health Care, retiring in 2007. As primary-care director, Slaton was part of a small group that planned, developed, and implemented Passport Health Plan, which started in 1997 and became a national model for managed care of Medicaid patients.

As a member of the national advisory board of the Institute for Rural Journalism and Community Issues at the University of Kentucky, he was the catalyst for funding of the institute's Kentucky Health News by the Foundation for a Healthy Kentucky. Sitting with Institute Director Al Cross and then-Foundation President Susan Zepeda at a Kentucky Chamber of Commerce luncheon in 2010, he said, "Al, you ought to ask Susan for some money." When Zepeda asked what the money would be for, Cross (who had no idea the proposition was coming) replied that the goal would be improving health coverage in Kentucky news media. The foundation continues to fund Kentucky Health News.

Slaton later chaired the advisory board, helping the Institiute develop a strategic plan. He was a member of the foundation's Community Advisory Council and chair of the chamber's Health Care Policy Council. In 2018, he won the Russell E. Teague Award from the Kentucky Public Health Association for his achievements and contributions to public health.

"Throughout his career in both public service and as a health-care consultant, he provided a politically savvy perspective and an astute management style that enabled institutions and organizations to make significant headway in policy change to improve the health of Kentuckians," his obituary says. "Robert always believed that health care was a right, not a commodity, and he worked very hard in a variety of settings to help move it in that direction."

As health commissioner, "He demonstrated an understanding of social and structural determinants of health that was ahead of its time," the obituary says. "Robert was a consensus builder and a natural organizer who was described as generous and down-to-earth. His talents included problem solving, strategic planning, and organizing a group of people to get a project done. He was proud that over his career he had helped young staff members develop beyond what they thought they could do. He could often see what needed to be done before most people, and he could handle personalities and egos to bring about change in organizations. Robert focused much of his career on building linkages and coalitions between different groups. This was eased by his genuine rapport with people. Robert’s strategic planning skills, insightful opinions, and wise counsel were valued by many leaders in the business, nonprofit, and political world."

He was co-author of two books about management, From Green Persimmons to Cranky Parrots, and Caught in the Middle Management. At the time of his death, he was working on a book about his mother’s life, based on the diaries she kept for decades. As he moved into assisted living, Robert was already making plans for his next book, stories of his colorful adventures as a parole officer in Western Kentucky in the 1960s. He was a delegate to the 1992 Democratic convention.

Slaton is survived by five adult children, Andrea, Lyle, Tom, Danny (Elizabeth), and Mike (Jake), and three grandchildren: Thia, Henry, and Lila. He is also survived by his companion, Mary B. Bradley, and her two children, whom he very much thought of as his own: Lizi Hagan and Clay McClure.

A memorial service will be held at 10 a.m. ET Saturday, Dec. 31 at Pearson’s, 149 Breckenridge Lane, Louisville. Visitation will be held from 4 to 7 p.m. ET Dec. 30 at Pearson’s. In lieu of flowers, donations may be made to Down Syndrome of Louisville, the Foundation for a Healthy Kentucky, or the Institute for Rural Journalism and Community Issues.

Beshear joins 15 other Democratic attorneys general in seeking to block lawsuit aimed at striking down Affordable Care Act

Attorney General Andy Beshear has joined with 15 of his Democratic counterparts in other states seeking to intervene a lawsuit aimed at striking down the Patient Protection and Affordable Care Act.

The suit, filed in a Texas federal court by 18 attorneys general and two governors, claims that the 2010 law is unconstitutional because last year Congress eliminated the law's penalty for failing to purchase health insurance, known as the individual mandate.

The would-be interveners argue that a successful suit "would devastate the nation’s health care system, causing millions of people to lose access to quality, affordable insurance and cost the intervening states billions of dollars in federal funding," said a press release from Beshear's office.

Beshear said Kentucky would lose $49.7 billion in federal funding for its Medicaid expansion, which covers 493,000 people, and subsidies for the 90,000 people who bought Obamacare insurance plans, through 2028.

“Hundreds of thousands of Kentuckians are at risk of losing their health care coverage, many of whom have coverage for the first time,” he said in the release.

All the attorneys general who filed the suit are Republicans. Beshear is joined by other Democratic attorneys general in California, Connecticut, Delaware, Hawaii, Illinois, Massachusetts, North Carolina, New Jersey, New York, Oregon, Rhode Island, Virginia, Vermont, Washington and the District of Columbia. Beshear's release did not note any party affiliations. 

Ky. Hospital Assn. joins Bevin suit against 16 Kentuckians who say changes he and feds are making to Medicaid are illegal

By Melissa Patrick
Kentucky Health News

The Kentucky Hospital Association has joined Gov. Matt Bevin's federal lawsuit against the 16 Kentuckians who filed a suit that claims his changes to the state's Medicaid program are illegal, stating in the court document that Kentucky hospitals will "suffer an injury" if the court doesn't rule them to be legal. That is based on Bevin's threat to end the 2014 expansion of Medicaid if a court blocks his changes.

In January, 16 Kentuckians filed a lawsuit claiming that federal officials violated federal law and perhaps the U.S. Constitution by approving changes to Kentucky's Medicaid program and declaring their intent to approve similar changes in other states. The suit did not name Bevin or his subordinates as defendants. The plaintiffs are represented by the National Health Law Program, a public-interest law firm; the Kentucky Equal Justice Center; and the Southern Poverty Law Center.

In February, Bevin sued the Kentuckians and the groups representing them and asked for the case to be decided in Kentucky, and "seeks to ensure that, as the architect and administrator of the waiver, the Commonwealth's voice is heard," his office said in a press release.

The state's new Medicaid plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long Term Health," includes, among other things: work or training requirements, lock-out periods for failure to comply, and premiums and co-payments. The changes are set to be phased in, starting in July, and will largely impact Kentuckians who have gained Medicaid coverage through the expansion, which covers people with incomes up to 138 percent of the federal poverty level.

Bevin's threat to roll back the expansion program if Kentucky HEALTH is ruled unlawful seems to have pushed the hospital association to join his case.

KHA Senior Vice President Nancy Galvagni told the trade journal Inside Health Policy that hospitals plan to work with Medicaid recipients to help them meet the new requirements, Lisa Gillespie reports for WFPL.

“We’re supporting the waiver because we support expansion,” Galvagni told IHP. “We want to have the expansion in place, and if it’s contingent upon the waiver being in place, we want to make the waiver work.”

"If judges rule Bevin’s plan illegal and he makes good on his threat to completely do-away with Medicaid expansion, it would have a devastating impact on hospital finances," Gillespie writes. "Hospitals in Kentucky had $552 million in charity care costs in 2015 after the state expanded Medicaid. That compared with $2.4 billion in those costs from 2012."

KHA attorney Wesley Butler, of the Lexington-based law firm Barnett Benvenuti & Butler, told Gillespie that hospitals need to be included because health providers will be affected by the many changes.

“We recognize that the government has to make some difficult choices to manage a large program,” Butler said. “We would much rather us be proactive in managing those issues rather than allowing them to deteriorate as the program tends to do with a lack of innovation.”

The lawsuit says, “The absence of health care providers in this legal dispute would omit a principal party that actually provides the necessary health care services for a government health care program. . . . If the implementation of Kentucky HEALTH is found to violate the Constitution, its invalidation will have a state-wide impact on Kentucky health care providers.”

Gillespie points out that the Kentuckians' suit currently resides in the D.C. federal court under Judge James Boasberg, a judge appointed by former President Barack Obama. Most district judges in the Eastern District of Kentucky, where Bevin filed his suit, were appointed by Republican presidents.

Officials of Breckinridge hospital say it needs new tax to survive

Photo via Norton Healthcare

Officials of Breckinridge Memorial Hospital in Hardinsburg say the 25-bed, critical-access hospital is running out of money and can't survive without a new property tax in one of the state's most agriculture-dependent counties.

Tim Crockett, chief financial of Breckinridge Health Inc., told 150 to 200 people during a Feb. 21 forum at Breckinridge County High School that its savings are depleted despite actions to reduce costs. He blamed "health-care reform coupled with decreased Medicare and Medicaid reimbursements," as described by WXBC Radio in Hardinsburg.

Breckinridge Health, a nonprofit with a home-health service, a nursing facility and primary-care clinics, is seeking a dedicated tax of 10 cents per $100 worth of property. That would require 1,800 signatures on a petition to the county Fiscal Court, the station reports. "Attendees who spoke ranged from support for the proposed levy to concerns that only property owners would pay the increased cost. A second forum is scheduled for next Wednesday at 6 p.m. at the Frederick Fraize High School cafeteria" in Cloverport.

Breckinridge County (Wikipedia map)

Some responses to a survey placed in the Feb. 14 Breckinridge County Herald-News were reported in the weekly paper's Feb. 21 edition. One said, "I don't like taxes and we own considerable amounts of property [but] is our hospital not as important as [the] library, extension office, health department and more?" All have local, dedicated taxes. Another wrote, "Only someone who has been lucky enough to not need emergent medical care would be fool enough to not support our hospital."

The negative responses included, "The hospital has spent an enormous amount of money foolishly buying up excess property." Another wrote, "I love our hospital but we cannot afford any more money out of our fixed income. Why sneak to get it passed? Let the voters decide! Referring to the hospital's affiliation with Louisville-based Norton Healthcare, another wrote, "Our hospital can be saved whether we are taxed or not. It's a process of negotiation that needs to be explored with other financial entities."

McConnell tries to sell 'Medicaid Republicans' from Ohio, W.Va., 3 other states on new health-insurance bill; Paul remains opposed

Kentucky Health News

“By most measures,” writes Paul Kane of The Washington Post, Senate Majority Leader Mitch McConnell and his Republican allies “face a nearly impossible task of finding enough votes to pass their long-promised repeal of the Affordable Care Act,” because Sen. Rand Paul and the Senate's most moderate Republican say they oppose the bill, and that leaves McConnell with no votes to spare.

“Yet by one measure,” Kane adds, “Republicans have never been closer to actually repealing large chunks of what they dismiss as ‘Obamacare.’ Within two short weeks, the party will probably either be reveling in its unexpected victory or mired in deep infighting over the party’s failure to live up to a pledge it has made over the past seven years.”

That time frame may be extended a week. On Saturday night, McConnell postponed action on the bill by a week because Sen. John McCain is recuperating in Arizona from surgery to remove a blood clot above an eye.

McConnell is trying to pass the bill through "budget reconciliation," one exception to the Senate's 60-vote filibuster policy, because Republicans hold only 52 of the 100 Senate seats. But with Paul and Maine Sen. Susan Collins publicly opposed, McConnell needs to get every other Republican and a tie-breaking vote from Vice President Mike Pence.

"Some Republicans remain optimistic" that McConnell "can pull off the negotiating tricks necessary, but he still faces an uphill fight in winning the votes to pass the Better Care Reconciliation Act by his tentative deadline of Friday," July 21. Key House members told Kane that if the Senate passes the bill, their chamber would pass it and send it to President Trump.

Senate Majority Leader Mitch McConnell answered reporters'
questions in Bowling Green. (AP photo by Austin Anthony)

Trump put more pressure on McConnell July 12, saying "Mitch has to pull it off. He's working very hard. He's got to pull it off." If not, "I will be very angry about it."

Late Friday, July 14, McConnell met with five Republican senators who haven't agreed to his revised bill because it still phases out federal funding for the expansion of Medicaid and sets long-term Medicaid spending limits that would keep the program from keeping pace with health-care costs and force states to make cuts. Kentucky is one of the most Medicaid-dependent states.

"Dean Heller of Nevada, Lisa Murkowski of Alaska, Rob Portman of Ohio, Shelley Moore Capito of West Virginia and John Hoeven of North Dakota" asked McConnell "to rework proposed changes to Medicaid in exchange for their 'yes' votes," Fox News reported.

The Post reported earlier that McConnell told Capito and Portman that future Congresses are likely to block the cuts. That report concerned Wisconsin Sen. Ron Johnson, who said it put "in jeopardy" his vote for the motion to proceed with the bill.

The proposed Medicaid changes also concern hospitals, but "One hospital industry lobbyist said there has been no attempt by Republican leadership to have a serious discussion with industry lobbyists or leaders about how to change the bill to win their support," reports Yasmeen Abutaleb of the Reuters wire service. Likewise, when the six major physicians' lobbies made their first joint plea, against the bill, they didn't get to meet with McConnell, the Post reported.

An unnamed senator told Fox that McConnell was unlikely to relax the Medicaid spending formula but might give the holdout senators assurances about how $70 billion in insurance subsidies that he added to the bill would help "lower-income Americans buy insurance." Under the bill, people earning more than about $42,000 a year "would face sharp premium increases," The New York Times' Margot Sanger-Katz reports.

The private insurance market is a greater concern than ever because McConnell, to get support from Texas Sen. Ted Cruz and perhaps some of his ardently conservative allies, added to the bill a provision that would allow insurance companies sell low-cost, low-coverage policies, something Obamacare outlawed in order to help the companies cover people with pre-existing conditions and deal with other facets of the law.

The two largest groups in the health-insurance industry called the Cruz amendment "simply unworkable," saying it would jack up costs for sick or vulnerable people and limit options for those who buy individual plans.

The CEOs of America's Health Insurance Plans and the Blue Cross Blue Shield Association told McConnell and Minority Leader Chuck Schumer of New York) Friday that the amendment "would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market," and would create "two systems of insurance for healthy and sick people. As healthy people move to the less-regulated plans, those with significant medical needs will have no choice but to stay in the comprehensive plans, and premiums will skyrocket."

Kathryn Watson of CBS News notes, "The letter could be dismissed by Republicans, however, as the current head of AHIP is Marilyn Tavenner, who helped implement Obamacare as the head of the Center for Medicare and Medicaid Services."

Other major changes McConnell made in the bill would allow pre-tax income to be used to pay premiums through health savings accounts, used largely by those with above-average incomes, and add $45 billion for opioid-addiction treatment, a major concern in Kentucky, Ohio and West Virginia.

To pay for that and the insurance subsidies, McConnell dropped from the bill a planned repeal of three taxes that help finance Obamacare: a 3.8 percent levy on net investment income, a 0.9 percent Medicare payroll tax on people making $200,000 a year or couples earning $250,000, and a tax on highly paid health-insurance executives. "Lawmakers such as Sen. Bob Corker (R-Tenn.) said repealing those taxes would give too much relief to the wealthy at the expense of the poor," the Post reported.

McConnell could have room to add more money to the bill after Monday, July 17, when the Congressional Budget Office will estimate the measure's effect on revenue and spending.

Sen. Rand Paul

Meanwhile, Paul said McConnell's latest bill has nothing "remotely resembling repeal." Last week, he said he and his Kentucky Republican seatmate have had no negotiations about it.

Gov. Matt Bevin, speaking at the National Governors Association's summer meeting, "sharply criticized his party’s decision not to eliminate a pair of taxes on high earners," Jonathan Martin of the Times reports. “They’re going to lose as many votes as they’re getting,” Bevin said, adding that there had been an “understanding that those two taxes were going to be gone.”

McConnell has said that if Republicans can't pass a bill with their own votes, they will have to work with Democrats to stabilize the private insurance market.

"Across the country, Americans are losing choice and access under Obamacare," McConnell said in a speech on the Senate floor as he rolled out his revised bill. "Things are not likely to turn around unless we act."

Studies say Kentucky would be among biggest losers if current version of Senate Republicans' health-insurance bill became law

Few states would lose more of their federal health-care spending than Kentucky if the current version of the bill being pushed by Sen. Mitch McConnell became law, according to studies surveyed by the Lexington Herald-Leader.

"The left-leaning Center for American Progress estimated 231,400 fewer Kentuckians would have insurance in 2026 under the bill," reporter Bill Estep writes. "The non-partisan Urban Institute projected an even bigger impact: 541,000 more non-elderly Kentuckians without insurance in 2022 under the Senate bill than under the ACA, the law now in place that is commonly called Obamacare. That would push the number of uninsured people in Kentucky from 6.3 percent of the population to 21 percent, the study said. A cut in federal funding for Medicaid would be the key driver of that increase."

The projected drop in Kentucky Medicaid spending would be the largest of any state, because the expansion of the program under Obamacare gave Kentucky one of the biggest increases in Medicaid enrollment. The study estimated that enrollment, including the related Kentucky Children's Insurance Program, would fall by more than half.

That concerns Ben Chandler, president of the Foundation for a Healthy Kentucky, which commissioned a study that showed expansion brought "increases in the number of people with a regular source of care, fewer people putting off needed care because of the cost, and a big decline in people who said they had trouble paying for medical care," Estep reports. "The law also has brought in money for medical providers, and holds the potential to cut health costs in the long run by getting people into preventive care and heading off problems that are expensive to treat, Chandler said."

“Medicaid expansion has been valuable for Kentucky in several ways,” Chandler told Estep. “Our position is simple: the more people covered, the better.”

Estep notes: "Critics, though, argue that spending under Obamacare has added to the federal deficit and is unsustainable," and that when it comes to private insurance, "The law has driven up premiums and caused insurance companies to pull out of markets, leaving people with little choice of carriers." That has happened in Kentucky. McConnell "said in a Senate speech that Obamacare has caused premiums to increase by an average of 105 percent in most states in the federal exchange, and that more increases are projected."

Read more here: http://www.kentucky.com/news/state/article159246729.html#storylink=cpy

"Insurance premiums won’t necessarily decline, though, if the Senate bill becomes law," Estep writes. "An analysis by the Kaiser Family Foundation projected a 74 percent increase in the cost of the average monthly premium, after tax credits, for the benchmark insurance plan available through marketplace exchanges under the Senate bill. That was a nationwide number. The study said most people who bought insurance through the exchanges would pay more."

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.”

Bevin declines to join bipartisan group of governors' call for continuation of formula used to fund state Medicaid programs

By Al Cross and Melissa Patrick
Kentucky Health News

A bipartisan group of governors, including Kentucky Gov. Matt Bevin, is asking Congress not to shift health-care costs to the states, a real prospect as the Senate prepares to vote on a bill to repeal and replace the Patient Protection and Affordable Care Act.

However, Bevin declined to join the group's request to maintain federal funding rates for Medicaid, the program that covers 1.4 million Kentuckians and is in for big changes if Senate Republicans' health bill becomes law.

Bevin and Kentucky are part of the Governors' Bipartisan Health Reform Learning Network, organized by the National Governors Association Center for Best Practices. It has six Republican and seven Democratic governors from California, Delaware, Kentucky, Minnesota, Montana, Pennsylvania, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington and Wyoming.

The governors summarized their priorities Wednesday, as details of the Senate bill were leaking out. It would end the Medicaid expansion later than a bill passed by the House, but would use a less generous formula for funding state Medicaid programs, beginning in 2025.

A statement of "shared priorities" from the 13 governors in the network says, "It is critical that Congress . . . not shift costs to states. Significant cuts to Medicaid will impact coverage for millions of low-income individuals and could impede state efforts to address the underlying factors driving health care costs."

It also said, "For the majority of the network states that expanded Medicaid, maintaining coverage for those populations at the federal matching rate under current law is of critical importance. (With the exception of Kentucky which does not agree with this statement)."

Bevin's predecessor, Democrat Steve Beshear, expanded Medicaid to people in households with annual incomes up to 138 percent of the federal poverty level. The federal government paid the full cost of the expansion until this year. It is now paying 95 percent, which will drop in annual steps to the current law's floor of 90 percent in 2020.

For traditional Medicaid patients, the federal government pays about 70 percent of the costs, based on a formula that gives poorer states higher reimbursement rates.

The governor's office didn't immediately respond to a request for comment on why Bevin declined to support this part of the statement. During his 2015 campaign, Bevin initially said he would abolish the expansion, and even after dropping that idea, said federal money shouldn't be accepted just because it is available, because it is taxpayer money.

Under the bill to be revealed Thursday, Medicaid funding would use "an even slower growth index than the one used in the House bill," reports Paige Winfield Cunningham of The Washington Post. "That move could prompt states to reduce the size of their Medicaid programs."

The divide between dentistry and medicine can have deadly consequences; policymakers are getting more interested

(Photo from ancienthistorybulletin.ca)

As anyone who has ever mistakenly thought that medical insurance would cover their visit to the dentist knows, the worlds of medicine and dentistry don't overlap much.

They almost never overlap when it comes to education, insurance coverage or practice. Physicians go to medical school, and dentists go to dental school. Your doctor likely isn't concerned with whether you floss regularly, and your dentist is probably uninterested in your exercise habits.

But they probably should be, since the body doesn't know it's supposed to keep oral health problems separate from other medical issues, and the two commonly overlap. In fact, oral health problems can lead to dire medical complications if left untreated, according to the National Institute of Dental and Craniofacial Research.

Mary Otto explores this strange divide in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. One story that shapes Otto's book is the tragic case of 12-year-old Deamonte Driver, who died in 2007 after bacteria from an abscessed tooth infected his brain.

Otto discussed the history of dentistry, its practices and the cultural divide of good oral care in an interview with Julie Beck of The Atlantic magazine. She described the first push for reform in the 1920s by William Gies, a biological chemist.

"He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the health-care system. He said: 'Dentistry can no longer be accepted as mere tooth technology.' He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate," Otto told Beck.

Former Surgeon General David Satcher called for reform again in his 2000 report "Oral Health in America." "He said we must recognize that oral health and general health are inseparable," Otto said. "And that too, was a kind of challenge. And it seems like things are changing, but very slowly."

An an example of the effect of separating dentistry from medicine, Otto said more than a million Americans visit emergency rooms with dental problems each year.

"It costs the system more than a billion dollars a year for these visits," she told Beck. "And the patients very seldom get the kind of dental care they need for their underlying dental problems because dentists don’t work in emergency rooms very often. The patient gets maybe a prescription for an antibiotic and a pain medicine and is told to go visit his or her dentist. But a lot of these patients don’t have dentists. So there’s this dramatic reminder here that your oral health is part of your overall health, that drives you to the emergency room but you get to this gap where there’s no care."

Otto said that all the health-care programs we’ve had in our nation's history, including private insurance, have on some level neglected oral health or treated it as a fringe benefit. She said oral care highlights the economic inequality in America, because many dentists are focused on expensive, cosmetic procedures.

"Of course there is a lot more money to be made with some of these really high-end procedures. But on the other hand there’s this vast need for just basic, basic care," Otto told Beck. "A third of the country faces barriers in getting just the most routine preventive and restorative procedures that can keep people healthy."

Rural and poorer areas face shortages of dentists. Otto said a group of dental hygienists in South Carolina, where 250,000 children living in rural areas aren't getting dental care, fought to change state law so they could serve the needy kids without them first having to see a dentist. The dentists' lobby fought back, but the Federal Trade Commission stepped in and won the case for the hygienists "in the interest of getting economical preventive care to all these children who lacked it," Otto said.

Dentists say they're not to blame for such problems. "Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas, that we Americans need to value our care more and go out and find care more aggressively," Otto said. "They see the fault as being with society at large."

What does Otto see as the solution? She said something that needs to be discussed more in dentistry is the "Triple Aim," a concept discussed in planning for the Patient Protection and Affordable Care Act. It involves bending the cost curve toward prevention, expanding care more broadly and more cheaply, and creating a better quality of care.

"It seems like it’s capturing an increasing amount of attention from state lawmakers, governors, and public-health officials who are interested in bringing costs down for all kinds of health care and seeing that these things show promise," she said. "They're saying we’re spending too much on emergency rooms, we're spending too much on hospitalization for these preventable problems, so there are cost incentives to get more preventive and timely routine restorative care to people."

Paul says conservatives won't support Republican health plan, hope to negotiate one more to their liking with Trump involved

Sen. Rand Paul (ABC image)

By Al Cross
Kentucky Health News

Republican U.S. Sen. Rand Paul laid out his objections to House GOP leaders’ bill to replace the Patient Protection and Affordable Care Act on CBS’s “Face the Nation” Sunday.

Paul called for an end to federal mandates for what insurance policies must cover, which the 2010 law called “essential benefits.” He said that change would enable consumers to buy the sort of coverage they want, at lower prices.

“Premiums will keep rising because they do nothing to fix the fundamental problem,” Paul told interviewer John Dickerson.

He also objected to the bill’s taxes, its “bailouts” for the insurance industry and the 30 percent surcharge that an insurance company could impose on someone who goes without coverage for more than 63 days in 12 months.

The surcharge is effectively a substitute for the current law that requires almost all Americans to have health coverage.

“The individual market will get worse when you get rid of the individual mandate,” Paul said, arguing that if someone loses a job, there will no incentive to sign up until coverage is needed. “You can’t have an insurance model where people wait ‘til they’re sick to get insurance,” he said.

Dickerson asked Paul about Medicaid, which covers 1.3 million Kentuckians, including 440,000 added through expansion of the program under the reform law.

The bill would set the first spending limits for the program, beginning in 2020, but Paul questioned whether the limits would be effective because the limit would rise with one measurement of inflation.

“It’s still building in the growth of an entitlement program that really isn’t paid for,” Paul said. “We have no money; we borrow a million dollars a minute.”

Paul, who has long made the federal deficit and the national debt his signature issue, shares those concerns with the House Freedom Caucus, a group of Republican representatives. Together, they pose significant obstacles to the bill, which is starting in the House.

If enough Republicans oppose the bill, it cannot pass. Paul said that if it is not changed, it will not pass, and that would begin talks that would include President Trump.

“I don’t think the president is rigid in support of the House bill. I think he's open to seeing how we can get consensus,” Paul said. “If enough conservatives to say no to the rule, then true negotiation begins.”

Paul was an apparent object of Vice President Pence’s Saturday trip to Louisville, hosted by Gov. Matt Bevin, who said Friday that he was closer to Paul on the issue.

Paul told Dickerson, “Right now I think there’s a charm offensive going on. Everybody’s being nice to everybody because they want us to vote for this, but we’re not going to vote for it.”

Pence touts Republican health plan, seeking Sen. Paul's support; Democrats say vice president's remarks about Ky. are off base

Gov. Bevin and Vice President Pence (C-J photo by Sam Upshaw)

By Al Cross
Kentucky Health News

Kentucky again became the epicenter of the health-care debate on Saturday, as Vice President Mike Pence claimed in Louisville that "Kentucky is a textbook example of Obamacare's failures," while Democrats said Pence didn't know what he was talking about.

"Obamacare has failed the people of Kentucky, Obamacare has failed the people of America and Obamacare must go!" Pence told an invited audience of more than 100.

Pence, until recently governor of Indiana, cited rising premiums for federally subsidized policies sold on government exchanges and Louisville-based Humana Inc.'s planned departure from the exchanges, and claimed "Nearly half of the state only has one health insurer to choose from."

That's true only in the number of counties with one Obamacare insurer; most of them are relatively small. Rep. Andy Barr, R-Lexington, defending the Republican replacement bill on CNN after the event, said incorrectly, "Here in Kentucky almost 50 percent of the people have only one choice."

Pence continued, "One-third of the state is on Medicaid, and as your governor has said over and over again, it’s unsustainable. And Medicaid here in Kentucky is threatening to bankrupt this state." For a transcript of Pence's remarks, go to http://kyhealthnews.blogspot.com/p/r.html.

Gov. Matt Bevin, who introduced Pence at the energy-management firm Harshaw Trane, has asked federal officials to let him scale back the Obamacare expansion of Medicaid by his predecessor, Democrat Steve Beshear. President Trump's administration is expected to approve the request.

"As Bevin and Pence were denouncing Obamacare, supporters unleashed a flurry of tweets citing benefits of the law in Kentucky," reports The Courier-Journal's Deborah Yetter. Outside the event, "More than 600 people gathered along the road," The C-J reported. "Many of the protesters chanted, 'Save our care'."

At a press conference after the Republican event, Beshear said the expansion has had a positive impact on the state budget and economy, by funneling billions of federal dollars into the state's health-care system. He said of Pence, "He apparently has decided to join the governor in ignoring the facts about how successful the ACA has been in Kentucky and instead enter the world of alternative facts."

Beshear noted that more than 500,000 Kentuckians gained health coverage under the ACA, and that the state "saw its uninsured population drop from about 20 percent to about 7 percent," James Bruggers writes for The Courier-Journal. "But Kentuckians also voted for Trump, who campaigned on a promise to repeal and replace Obamacare."

"Beshear acknowledged there were problems with parts of Obamacare, such as limited participation by insurance companies in some states or counties," Bruggers reports. "But he said Republican critics caused that by creating too much uncertainty. As a result, he said, some insurers 'are sitting on the sidelines'. He said he'd like the two parties to work together on solving those problems."

Rep. John Yarmuth of Louisville, the only Democrat in the Kentucky congressional delegation, told WHAS-TV, said the Republican bill "would devastate places like Kentucky, which have very poor populations and desperate need for health care."

Yarmuth said in a CNN interview that Obamacare "is definitely sustainable," but "Insurance markets need work." He said he favors allowing people to "buy into Medicare. But I don't get total agreement on that from many people."

Yarmuth said Pence came to put pressure on U.S. Sen. Rand Paul, who has called the Republican health bill "Obamacare lite." Paul said Saturday, "What's going on behind the scenes this week is a charm offensive." Paul will be on CBS's "Face the Nation" Sunday.

Pence didn't mention Paul in his speech, but said, "Now I know that not every politician in Kentucky supports our plan to repeal and replace Obamacare. I know your former governor, Steve Beshear has been defending Obamacare all over America." He called Beshear is a friend with whom he had worked, "but your former governor is wrong about Obamacare."

Pence complimented 2nd District U.S. Rep. Brett Guthrie, R-Bowling Green, for supporting the bill in committee. "We need every Republican in Congress, and we're counting on Kentucky," he said.

First District Rep. James Comer said in a brief interview Saturday that he was leaning toward supporting the bill. Fourth District Rep. Thomas Massie, R-Vanceburg, a Paul ally, told The Washington Examiner that the bill is "a stinking pile of garbage."

Bevin told reporters Friday that he is closer to Paul on the issue. "Senator Paul has ideas; he thinks it needs to be a lot stronger. He's not as impressed with what has currently been offered as some who have currently offered it. Truth be told, I'm not either, so I'm with him. I think there are things that need to be done. We don't need another version of the same thing."

Bevin said the Medicaid expansion "is not working well. It's coming at a price that's unaffordable . . . While we have enrolled a lot of people, we haven't made people healthier, we really have not, nor are we on track to do it, and we're on track basically to break the system."

Bevin has noted that few Medicaid members get regular checkups. On the other hand, a survey of low-income Kentuckians found they had become more likely to say they were in excellent health than their counterparts in Texas, which didn't expand Medicaid. The researchers wrote, "Significant impacts of Medicaid expansion may take several years to unfold."

Bevin also told reporters, "We have rural hospitals that, rather than becoming stronger, have failed since the implementation of this in Kentucky. We have doctors that have given up their practices; some have retired, some have sold out. We have fewer and fewer doctors who are even willing to see Medicaid patients." Bevin's office has not responded to a request for evidence supporting that statement.

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

By Danielle Ray and Al Cross

Kentucky Health News

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

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

Medicaid expansion would be phased out

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

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

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

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

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

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

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

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

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

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

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

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

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

Private insurance would change

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

Graphic from The Economist

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

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

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

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

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

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

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

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

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

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

Ky. enrollment in Obamacare plans slightly less than last year

About the same number of Kentuckians signed up for subsidized health insurance on the federal health-insurance exchange as bought coverage on the state's Kynect exchange last year, state health officials announced Tuesday.

The Cabinet for Health and Family Services said 81,155 Kentuckians enrolled in federally qualified health plans on www.healthcare.gov during the three-month enrollment period that ended Jan. 31. That was 1.8 percent less than the year before, when 82,681 Kentuckians bought a plan on Kynect.

“These numbers clearly show the transition to the federal marketplace was a success,” cabinet Secretary Vickie Yates Brown Glisson said in a news release. “We have worked very hard to make sure this change produced minimal impact on consumers so that, at the end of the day, someone purchasing insurance through the federal marketplace was simply moving from one website to another.”

Gov. Matt Bevin pledged to close Kynect, but didn't go quite that far. He kept the exchange for insurance companies, which wanted a state-based exchange, but shifted consumers' enrollment to the federal exchange.

Under that setup, the federal government handles consumers' eligibility appeals, but the state reviews insurance companies' plan offerings and handles insurance-company grievances. Consumer grievances are handled by a state-federal partnership.

Kynect was funded by a 1 percent fee on all health-insurance policies sold in the state. Bevin said it wasn't fair for all insurance customers to pay for an exchange that 82,000 people use. However, his administration left the the fee in place, saying it is needed to help pay transition costs, fund the Kentucky Health Information Exchange and fund "legacy costs" of Kentucky Access, the high-risk insurance pool for which the fee was originally established – and transformed into Kynect funding by an executive order from then-Gov. Steve Beshear.

Ben Chandler, president of the Foundation for a Healthy Kentucky, hailed the enrollment numbers, but noted implicitly that the main impact of Obamacare in Kentucky has been Beshear's expansion of Medicaid to people with household incomes up to 138 percent of the federal poverty level.

“It's great news that enrollment in marketplace health plans this year is comparable to last year,” Chandler said. “The idea is to get more people insured, and this news is evidence that's happening. Toward the same goal – getting more people covered – we are pleased that Gov. Bevin is working to keep Medicaid expansion in Kentucky. Our research shows that the number of Kentuckians covered by Medicaid has increased by more than 500,000 people since 2010.”

Republican health-law drafts would reduce federal support for Medicaid and subsidies of private insurance

Kentucky would have to keep paying more for Medicaid, and people with federally subsidized health insurance would get less support, under a committee draft of a bill to repeal and replace the Patient Protection and Affordable Care Act.

"States that grew their Medicaid programs under the health law could maintain their expanded programs until 2020 before federal funding would decrease," The Wall Street Journal reports on the draft by the House Energy and Commerce Committee.

Then-Gov. Steve Beshear expanded Medicaid in 2014, adding 440,000 Kentuckians with incomes up to 138 percent of the federal poverty line. The state is paying 5 percent of this year's cost, and current law calls for that to increase in annual steps to 10 percent in 2020.

The House committee draft would shrink the federal share and require states to pay more, starting in 2020. The federal government pays about 70 percent of traditional Medicaid costs in Kentucky.

"Starting on Jan. 1, 2020, the federal government would begin to reimburse states at a lower rate as they transition to a system in which states would get a set amount of funding, tied to the size of their Medicaid population, along with more flexibility on how they could spend it," the Journal reports.

"The proposal is aimed at appealing to centrist Republicans who haven’t wanted to see the most generous federal funding for the program abruptly withdrawn, which could cause states to shrink Medicaid rolls. Some conservative Republicans have pressed for a more immediate rollback of the program."

Rep. Brett Guthrie

Among those are 2nd District Rep. Brett Guthrie, R-Bowling Green, who said of 2020, “Some people thought that was too far in the distance.”

Conservatives are focused on reducing the cost of the program. Under the committee draft, federal Medicaid spending would increase with the "chained" consumer price index, plus 1 percentage point. "The chained CPI usually shows slower inflation than the index used currently," the Journal notes. "Critics worry, however, that using chained CPI, which will reflect growth slower than the rise in health-care costs, would cause the government’s funding to fall short of needs."

The biggest obstacle to a new Medicaid program may be differences between states that expanded it and those that did not. The Journal notes that Republicans from the latter states "have balked at the idea of a plan that would reward states that did," many controlled by Republicans.

Kentucky is in an unusual position because its program was expanded by a Democratic governor without the involvement of the legislature, where Senate Republicans could have blocked it, but now the state is fully controlled by Republicans.

In his primary campaign, Gov. Matt Bevin said he would abolish the expansion, but after being nominated said he would scale it back, following an Indiana model that charges small, income-based premiums and imposes certain work requirements. His request to do that is pending before federal officials, one of whom helped draft the Indiana plan.

The broader political problem for Republicans is described by William Galston of the Brookings Institution: "The states that Donald Trump carried in 2016 disproportionately benefitted from the expansion of Medicaid that was one of the building-blocks of Obamacare, and they will suffer disproportionately from Medicaid cuts. Between 2013 and 2016, Gallup finds, the three states with the largest percentage-point reductions in their populations without health-care coverage were Kentucky, Arkansas, and West Virginia." All expanded Medicaid.

Private, subsidized insurance

In addition to Medicaid expansion, the ACA provided subsidies for private insurance bought on government exchanges: tax credits for people with incomes up to four times the poverty level, and cost-sharing for those up to 250 percent of the poverty line, to provide lower deductibles and copays on plans that cover a larger share of expenses.

For a larger version of either chart, click on the image

Under GOP replacement plans that have been publicly discussed, the subsidies would be at least a third less than now offered, and would rise more slowly over time, says the Kaiser Family Foundation.

"People who are lower income, older, or live in high premium areas would be particularly disadvantaged," Kaiser reports on its analysis.

Under a discussion draft circulated by House leaders, "The average tax credit for current ACA marketplace enrollees would rise from an estimated $2,957 in 2020 to $3,729 in 2027. By comparison, the average tax credit under the ACA would be $4,615 in 2020, increasing to $6,648 in 2027," Kaiser reports.

The three major Republican proposals' tax credits "vary with age but not income and grow annually with inflation," Kaiser notes. Current tax credits "vary with family income and the cost of insurance where people live, as well as age, and grow annually if premiums increase. These various tax credit approaches can have quite different implications for different groups of individual market purchasers.  For example, the tax credits under the ACA are higher for people with lower incomes than for people with higher incomes."

Republican proposals would also provide tax credits to people who don't now get them. Some Republicans have said no subsidies should go to people above a certain income level.

Beshear, Republicans debate the record of Obamacare in Ky.

Kentucky's roles in implementing and changing federal health-care law were on national display Tuesday night, as former Gov. Steve Beshear gave the televised Democratic response to President Trump's first address to Congress and Kentucky Republicans criticized Beshear's embrace of "Obamacare."

Trump set the table in his speech, using Kentucky as an example of why the Patient Protection and Affordable Care Act should be repealed and replaced: "Governor Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing." Trump has yet to endorse a replacement plan, but he said five principles should guide Congress:

• Americans with pre-existing conditions should "have access to coverage." Republicans talk about doing that through insurance pools for higher-risk people, which require government subsidies to work. Critics say many people still couldn't afford insurance from high-risk pools, which Kentucky once had.
• Regular coverage should be subsidized through tax credits and expanded use of health savings accounts, which are exempt from taxes, and people must get "the plan they want, not the plan forced on them by the government." The ACA set minimum requirements for coverage, making it more expensive, especially for people who had bought low-cost policies.
• "We should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out." Republicans talk about giving states block grants for Medicaid, with few strings attached but limiting federal funding of the program. There is debate about how to equitably fund states that expanded Medicaid under the ACA and those that didn't.
• "We should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance. and work to bring down the artificially high price of drugs and bring them down immediately."
• "The time has come to give Americans the freedom to purchase health insurance across state lines, creating a truly competitive national marketplace that will bring cost way down and provide far better care."

Beshear, speaking from the downtown Lexington Diner, said "So far, every Republican idea to replace the Affordable Care Act would reduce the number of Americans covered, despite your promises to the contrary."

Trump said in January that he wanted "insurance for everybody," and presidential adviser Kellyanne Conway promised that no one would lose their insurance. "However, an analysis of the current Republican plan to replace the health-care law shows that millions who have coverage today would lose it," NPR health correspondent Alison Kodjak reported, citing a presentation made to the National Governors Association last weekend.

Beshear continued, "Mister President, folks here in in Kentucky expect you to keep your word, because this isn't a game, it’s life and death for people. These ideas promise access to care, but deny the importance of making care affordable and effective. They would charge families more for fewer benefits and put the insurance companies back in control."

Kodjak says the Republican approach "could help reduce premiums for those who would like to buy a more stripped-down insurance policy," but the draft plan of House Republicans is "likely less generous, so people could pay more for health care even if they have lower premiums."

Beshear accused Republicans of thinking "that folks at the lower end of the economic ladder just don't deserve health care. That it is somehow their fault that their employer doesn't offer insurance or that they can't afford to buy expensive health plans." He added later, "Before the Affordable Care Act, they woke up every morning and went to work, just hoping and praying they wouldn't get sick because they knew that they were just one bad diagnosis away from bankruptcy."

When he was governor, Beshear expanded Medicaid to people earning up to 138 percent of the federal poverty level, now $16,394 for an individual or $33,534 for a family of four. As a result, the share of Kentuckians without health insurance dropped to 6 percent from 14 percent, the largest reduction of any state.

Bevin says the state can't afford to pay its 5 to 10 percent share of the expansion cost, and has asked federal officials to waive rules and let the state charge Medicaid enrollees small, income-based premiums and require able-bodied adults who are not primary caregivers to work or perform work-related activities. The Trump administration is expected to approve the waiver.

Speaking to reporters in Washington Monday, Bevin said of Beshear, "Because he unilaterally chose to expand Medicaid in Kentucky, enrolled hundreds of thousands of people, the net result of it has been a remarkable decline in access to health-care coverage: more people covered, but covered by what? Fewer people able actually to even see a doctor." Then he immediately started talking about private insurance, noting that half of Kentucky's counties have only one Obamacare provider. "There are only three now in the entire state, only one that covers the entire state."

Asked how the expansion could have reduced access to coverage when it added 440,000 Kentuckians to Medicaid, Bevin communications director Amanda Stamper said in an email that the governor was "referring to more than simply Medicaid expansion," and "the loss of quality health care coverage and shrinking networks. Medicaid coverage is not quality health coverage. Network adequacy is an issue, as fewer and fewer doctors want to deal with [the] administrative burden of accepting Medicaid for reimbursements that do not cover their cost."

Stamper added that the current version of Medicaid coverage "does nothing to engage the beneficiary or incentivize behaviors that will lead to better health outcomes. A study that looked at the expansion population found that only 10 percent of Kentucky expansion beneficiaries received an annual wellness or physical exam. That is not the kind of utilization that will drive better health outcomes."

State Senate Floor Leader Damon Thayer, R-Georgetown, delivered a response to Beshear's response. It can be viewed on the state Republican Party's Facebook page.

Longtime Whitesburg doctor, winner of national honor, fears patients will lose Affordable Care Act's preventive care

Dr. Van Breeding (Lexington Herald-Leader photo)

Whitesburg physician Dr. Van Breeding says his patients got "bamboozled" by politicians who tagged their expanded access to health care as "Obamacare."

Barack Obama, who was anti-coal, is deeply unpopular in coal-friendly Appalachian towns like Whitesburg; thus, any program bearing his name was doomed to suffer the same fate, Breeding told Cheryl Truman of the Lexington Herald-Leader.

Breeding, a primary-care physician and clinical director at Mountain Comprehensive Health Corp., was named the 2017 Staff Care Country Doctor of the Year. The Texas-based medical staffing company began awarding the honor in 1992. Breeding is the first Kentuckian to receive the award since 1997, when Claire Louise Caudill of Morehead was awarded the title, Truman notes.

"He takes care of patients from birth to death, from hospital to nursing home," Truman writes. "He is a bit suspicious of 'hospitalists,' because who can take care of you better than the doctor who knows you, your family, your family tree and the ailments that have befallen your kin?"

Breeding, a Letcher County native, got his degrees from the University of Kentucky and was a medical resident there, but he told Truman always knew he wanted to return home to practice medicine. The Patient Protection and Affordable Care Act brought more patients to Breeding and the clinics at which he works.

"We got insurance to patients who have never had care before," Breeding told Truman.

Now Breeding fears his patients will lose that insurance. President Donald Trump campaigned on a promise to repeal the ACA as one of his first orders of business, and Republicans are formulating options for a replacement. Compare some of the proposals here.

The 2010 reform law provided opportunities for free preventive care, to which some of Breeding's patients had never had access before Kentucky expanded Medicaid under the law in 2014.

"In Eastern and southeastern Kentucky, getting patients in for early screenings is crucial," Truman writes. "The area has high rates of breast, uterine, ovarian and colon cancers, and patients benefit from early detection."

Breeding, 55, sympathizes with patients who struggle to stretch money until the end of the month, "so he tries to schedule appointments earlier in the month, when patients can buy gas to get to the clinic," Truman writes. "His patients can’t take a bus, like Lexington patients, and a filled gas tank is required to get just about anywhere in the mountains."