Ky. health-system performance ranked 41st, Covid-19 response 49th; highest hospitalization rate, relatively low vaccination rate

Chart from 2022 Scorecard on State Health System Performance, The Commonwealth Fund

By Melissa Patrick
Kentucky Health News

Kentucky ranks 41st among the states and Washington, D.C. in the latest ranking of states' health systems, but when it comes to how well those systems and their states' populations have handled the pandemic, Kentucky ranked 49th, ahead of only Alabama and Oklahoma.

The rankings are done annually by The Commonwealth Fund, a New York-based foundation that says it aims to promote a high-performing health-care system. In past years, the Scorecard on State Health System Performance has asked three questions: 

• Do Americans have good access to health care? Does their health insurance enable them to get the care they need to stay healthy? Are they protected from high out-of-pocket health costs?
• Are Americans getting the right health care, at the right time, and in the right setting? To what extent are they seeking care from emergency departments or other costly settings instead of visiting a primary care provider? Has health care use and spending gone up or down?
• How healthy is America? How prevalent are high-risk behaviors like smoking or health conditions like obesity that put people at higher risk for poor health? What are Americans’ chances of dying early in life from preventable or treatable causes?

This year, the fund added a question: "How well has each state responded to and managed the Covid-19 pandemic?"

"Covid-19 has disrupted aspects of care and we wanted to take a closer look at how states have responded," said David Radley, senior scientist at the fund, said in an online press briefing.

To do that, the researchers used seven metrics for Covid-19 through March 2022: hospitalization rates (Kentucky was No.1), stress on intensive-care units, hospital staffing shortages, deaths in nursing homes and overall, percentage of adults vaccinated and boosted, and the number of days it took to get 70% of the state's 12-and-over population fully vaccinated. Kentucky is one of 21 states that still hasn't achieved that; the scorecard ranked it 31st in vaccination.

Graph from Scorecard on State Health System Performance; for a larger version, click on it.

While the scorecard is for state health systems, Radley acknowledged that it also reflects the choices of a state's residents. Noting Kentucky's relatively low vaccination rate, he said that even if the state made a strong effort to get Kentuckians vaccinated, "People also have to be willing to get the shot."

Overall, the scorecard evaluated states on 56 health-care indicators in seven areas: access and affordability, prevention and treatment, avoidable hospital use and cost, healthy lives, which includes things like  premature death, health status and risky behaviors, income disparity, racial and ethnic equity, and the new Covid-19 indicators. 

Kentucky's top rankings were in racial and ethnic equity (21st), prevention and treatment (22nd), and access and affordability (32nd). It ranked 43rd for income disparity, and ranked 49th in three measures: Covid-19, avoidable hospital use and cost and healthy lives. The last four are reflections of the state's low health status, which the report ranked second from the bottom.

Among indicators used to measure the above categories, Kentucky's best were its percentage of home- health patients with improved mobility, ranked 10th; the infant death rate (11th) and percentage of uninsured adults (12th). The state's expansion of Medicaid under the Patient Protection and Affordable Care Act gave it perhaps the nation's largest reduction in the percentage of residents without health insurance.

Kentucky's bottom-ranked indicators, other than worst of all in Covid-19 hospitalizations, were adults who report fair or poor health, adults without a dental visit in the past year, adults who have lost six or more teeth, adults who smoke, children who are overweight or obese (all next to last)) and preventable hospitalizations of seniors (47th, or fourth from the worst). 

In the overall ranking of health systems, Kentucky was sixth among the 12 southeastern states (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia).

Kentucky's pandemic management and outcomes

The scorecard shows the impact of the pandemic on each of the measured domains; states that entered the pandemic with stronger health status and systems fared better with the pandemic. Hawaii, Maine, Vermont, Washington, and Oregon ranked tops in handling the pandemic, while Alabama, Oklahoma, Kentucky, Mississippi, and Georgia ranked at the bottom.

Commonwealth Fund table, adapted by Ky. Health News; click it to enlarge

Among the seven indicators used to measure the Covid-19 response in states and Washington, D.C., Kentucky ranked ninth worst (43rd) for Covid-19 deaths among nursing home residents. 

And despite a huge effort by state officials to get Kentuckians vaccinated, the state ranked 34th in percentage of fully vaccinated adults who had gotten a booster shot by the end of March 2022 (31%)

Kentucky ranked 39th for three Covid-19 indicators: days of high use of intensive-care units (126 days); days of hospital staffing shortages (180); and excess deaths from February 2020 through March 2022. Excess deaths are the number above what would have been expected from historic mortality patterns; they include Covid-19 deaths.

"Because the pandemic disrupted their ability to get timely care for conditions other than Covid-19, many more people likely died sooner than they otherwise would have," says the report.

Asked if these rankings have more to do with the strength or weakness of the state's health-care systems than states' policies to address the pandemic, Sara Collins, vice-president of coverage and access for The Commonwealth Fund, said it's important to look at the whole picture to understand why Kentucky has such a low Covid-19 score.

Collins said "It is striking" that Kentucky ranked so low after expanding Medicaid and having a low uninsured rate, but it also has high Covid-19 hospitalization rates and a highly vulnerable population that has high levels of pre-existing health conditions like obesity and smoking. 

"It just goes to show you that coverage is a necessary condition for access to health care and good outcomes, but it is not a sufficient condition," she said.

The state Cabinet for Health and Family Services was asked for comment on Kentucky's ranking of 49th in handling the pandemic, but did not respond before the 12:01 a.m. Thursday time of publication.

Other indicators affected by the pandemic

The indicator that worsened most in Kentucky during the pandemic was drug-overdose deaths. Kentucky ranked third for this measure, with 49 overdose deaths per 100,000 residents, a 51% increase from 2019 to 2020. 

Graph from Scorecard on State Health System Performance; to enlarge, click on it.

"Immediately after the pandemic began, deaths spiked, as people dealt with physical isolation, disrupted addiction treatment, and a supply of deadlier drugs like fentanyl," says the report.

The latest overdose-death report in Kentucky shows  that while this rate continues to go up, it increased by much less from 2020 to 2021, when it went up 14.6%.  

Kentucky also had one of the highest rates for deaths from treatable conditions (such as heart disease and diabetes) before age 75. Kentucky ranked seventh for this indicator, with 113 premature deaths from treatable causes per 100,000 residents. This increase is largely attributed to people postponing routine health services because of Covid-19, says the report. 

Dr. David Blumenthal, president of The Commonwealth Fund, told reporters that as the U.S. faces an ongoing public-health crisis, it is important for states to prioritize policy solutions that focus on equity, safety and health. 

"Lawmakers should look for ways to ensure that people can get the health care they need, shoring up the health insurance safety net and building on coverage gains achieved during the pandemic," he said. "Finally, states need to invest in their health-care infrastructure. As the scorecard shows high performing health care systems that provide comprehensive, high quality care every day, also performed better during a pandemic. Having a strong health care system is the best preparation for any public health crisis." 

The report's findings are based on the authors’ analysis of the most recent publicly available data from federal agencies including the U.S. Census Bureau, Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services, as well as other data sources.    

Appalachian counties continue to dominate lowest level of County Health Rankings in Ky.; most counties moved at least 10 notches

By Melissa Patrick
Kentucky Health News

The annual County Health Rankings & Roadmaps report, showing how the health status of every county in the United States compares to that of every other county in the state, has been released.

Many Kentucky counties showed little change, but 76 of the state's 120 counties shifted up or down by at least 10 notches in the rankings, which essentially measure of how long and how well we live. 

The rankings measure health outcomes, gauged by life expectancy and measures of quality of life; and health factors, such as access to physicians and areas to exercise, tobacco use, children living in poverty, violent crime, long commutes and other environmental factors. The report is issued by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

The rankings are meant to be viewed more as a general categorization of a county's health status, rather than making specific comparisons with counties that are relatively close in the rankings. Because the differences in rankings for most counties are so small that they are statistically insignificant, the researchers have placed counties in four groups of 30 counties each, called quartiles (each with one-fourth of the total of 120 counties). 

The bottom quartile for both health outcomes and health actors in Kentucky continues to be made up of almost entirely Appalachian counties. The exceptions for health outcomes are Carroll County, between Louisville and Cincinnati, and Fulton County, at the state's western tip. The relatively poor county is the only non-Appalachian county in the bottom quartile for health factors. 

In health outcomes, Fulton County moved down 17 spots from last year's report to rank 116th. Owsley County ranks 117th, followed by Perry County, which dropped 22 spots from last year's ranking, and Wolfe and Breathitt counties. The last four counties form a cluster.

Oldham and Boone, two of Kentucky's wealthiest counties, continue to be the top two in health outcomes, as they have been since 2011. No. 3, Scott County, has ranked between fifth and eighth since 2011. Campbell County in Northern Kentucky ranked fourth for the second year in a row and Calloway County, home of Murray, ranked fifth after moving up 19 notches from last year's rankings. 

Oldham and Boone are also the top two counties for health factors, and have been since 2015. They have been in the top five since 2011. Woodford, Campbell and Fayette counties are ranked third, fourth and fifth, respectively, for the second year in a row. 

The bottom five counties for health factors are Breathitt, Lee, Clay, Harlan and McCreary, all in Appalachian Kentucky.

Some big changes in health outcomes

Altogether, 26 Kentucky counties improved more than 10 notches in health outcomes from last year, and 13 of them improved by more than 20 places; 27 of them dropped more than 10, and 12 of those dropped by more than 20. 

Edmonson County improved the most for health outcomes, with a 50-notch jump up to No. 31 and the second quartile. However, its No. 81 rank last year was not typical for the county, which had been in the second quartile for health outcomes most years since 2011, so its latest rank is a return to form.

Several counties showed big improvements that moved them into the first quartile for health outcomes. Graves County improved 29 notches, to No. 28 from No. 57; Carlisle moved up to 20th from 45th; and Livingston moved up to 26th from 46th. 

Breckinridge County also saw a 37-notch gain (to 35th from 72nd) in outcomes that moved it into the second quartile.

Because the rankings are relative, county to county, they tend to have about as many drops as gains. Bracken County saw the greatest drop in health outcomes, 46 notches, to 81st from 35th. Clark County had the second greatest drop for outcomes (30th to 70th), moving from the first quartile to the third.   

Two Appalachian coalfield counties also saw big drops in outcomes, which moved them into the bottom quartile. Johnson fell to 96th from 71st, and Whitley dropped to 100th from 67th.  

Some big changes in health factors

Twelve Kentucky counties improved more than 10 notches for health factors, with three improving by more than 20. Eleven counties fell more than 10 notches; only one moved down by more than 20.

Livingston and Crittenden counties showed the most improvement for health factors. The adjoining counties in West Kentucky each moved up 24 slots into the second quartile. Livingston moved to 46th from 70th and Crittenden moved to 54th from 78th.  

Allen County's 17-notch improvement in health factors moved it into the 55th from 72nd, and into the second quartile. Simpson County moved into the first quartile by rising to 29th from 39th.  

McLean County had by far the biggest drop in health factors, falling 24 notches to 80th from 56th, which moved it down to the third quartile. Gallatin County fell to 65th from 53rd and Montgomery County fell to 62nd from 46th, both moving to the third quartile. Henry County dropped to 38th from 25th, moving it to the second quartile.

The report challenges Kentucky counties to take this data and turn it into action. Evidence-based resources to do that can be found in the "Take Action To Improve Health" section of its website. Here are the rankings (click image to enlarge):

Local collaborations help tackle Ky.'s health problems, and can be guided by hospitals' and health departments' needs assessments

By Melissa Patrick
Kentucky Health News

Collaborations in individual communities can play a critical role when it comes to improving Kentucky's poor health outcomes, largely because those outcomes are grounded in behaviors and unmet social needs at the community level.

That was the underlying message of the June 10 webinar hosted by the Foundation for a Healthy Kentucky, "Transforming Kentucky's Public Health System: The Critical Role of Community Collaborations." 

"There's a huge need for these coalitions because our health rankings are in the toilet and they've been in the toilet for quite some time," Ben Chandler, president and CEO of the foundation, told Kentucky Health News. "So much of the poor health resides in counties where they have lots of other issues." 

Those other issues are often called "social determinants of health" and include things like housing, transportation, food insecurity, education, healthcare and employment. Researchers have said they account for 80 percent of health outcomes. 

Kentucky ranked 48th for health behaviors and 46th for health outcomes in the last America's Health Rankings report from the United Health Foundation. 

Chandler noted that while the U.S. spends twice as much money on health care as other developed nations, it has worse outcomes. 

"So what it boils down to is, we've got to spend more of our resources working on changing people's behavior," he said. "And that sort of thing, I believe can only be done through public policy and at the community level; each community has to be involved." 

Many of these coalitions already exist in Kentucky, but Chandler said there is a need for more and a need to rejuvenate some that already exist. 

The Muhlenberg County Health Coalition is an example of one that is thriving. 

Jessica Browning, chairperson for the coalition, explained that this coalition was initially created to address the findings of the 2018 community health needs assessment of Owensboro Health Muhlenberg Community Hospital's, where she is the marketing director, and includes representatives from all sectors of the community. 

Tax-exempt hospitals like Muhlenberg must do community needs assessments every three years, under the 2010 Patient Protection and Affordable Care Act, with the expectation that they use them to create plans to address the identified community health needs. Some do, and some don't, but Chandler said they are a great tool to guide community collaborations.

Browning walked through several of the collaborative's initiatives, including efforts to make information about community and health resources easily available to the county's most vulnerable residents. The coalition also offers a community resource day twice a month, has found ways to address the county's homeless and housing issues, and has secured a grant to ensure affordable transportation for people who needed rides to work, school and medical appointments.

The Purchase Area Health Connections coalition in has also created a searchable database of resources in Kentucky's far west to make it easier for citizens to find the resources they need. 

Kaitlyn Krolikowski, network director of the coalition, said two of its largest initiatives are an opioid task force and a transitional care team of community health workers who work to reduce hospital readmission rates. CHWs are not health-care providers but educate people about care and help them get it.

The Purchase coalition's website shows that it also works on issues around childhood obesity, diabetes, mental health and more.

Krolikowski said the coalition formed when community members realized it would make the best use of their resources if everyone worked toward the findings of a regional community health needs assessment. She said the coalition's first meeting served as a "catalyst moment" to create different partnerships. 

Community collaborations have also been important to the state's local health departments, especially as it moves to a new model of operation, dubbed Public Health Transformation. 

Public Health Transformation was launched in 2019 and became law in 2020. Among other things, it establishes four "core public health" services that must be provided, those required by law or regulation. It also requires departments to do community health assessments, which many already do, to determine local health priorities beyond the core requirements. Those local priorities are funded separately. 

Jan Chamness, the state's Public Health Transformation project leader and director of the Division for Women's Health, said the transformation depends on strengthening partnerships in a community and allows health departments to collaborate with community partners to achieve their local priorities. 

For example, she said some departments have turned their women's health services and school health programs over to federally qualified health centers, clinics that get federal funds for meeting federal rules.

Public Health Transformation came about because of the fiscal instability of the health departments and because their services had evolved to not reflect their community needs, Chamness said. 

"What we're doing is not really working that well and so we really need to transform public health to be more responsive," she said.

Ky. has one of 5 highest death rates in U.S.; UK public-health dean calls it most 'comprehensive, inclusive' measure of health

Kentucky is one of the top five states for the highest death rates, according to a new study that compared mortality patterns between the five states with the highest and lowest death rates.

Donna Arnett, dean of the University of Kentucky College of Public Health, in an e-mail called death rates the most "comprehensive, inclusive" measure of overall health status.

Kentucky was joined by Alabama, Mississippi, Oklahoma and West Virginia for the five states with the highest death rates. California, Connecticut, Hawaii, Minnesota and New York were the five states with the lowest death rates.

It's no secret that Kentucky struggles in just about every area of health, ranking 49th in senior health and 45th in adult health, according to the latest America's Health Ranking Report. And even in areas where the state has made some progress, such as cancer screening, outcomes are still pretty dismal. So it should come as no surprise that the state ranks high in death rates.

Using 2017 data, the Centers for Disease Control and Prevention study compared the average age-adjusted death rates by sex, race and ethnicity, as well as the five leading causes of death between each group of states. Age specific death rates were given as well.

Click on any chart to see a larger version

It found that the average age-adjusted death rate for the five states with the highest rate (926.8 deaths per 100,000 people) was 49 percent higher than the overall rate for the five states with the lowest death rates (624 per 100,000).

Compared to the national average of 731 deaths per 100,000 people, the average death rate for the states with the highest rate was 27% higher, while the average death rate for the states with the lowest rates was 15% lower.

The death rates for ages 25-34 and 35-44 for the states with the highest death rates were more than double compared with the states with the lowest rates. The smallest percentage difference in rates was for persons aged 85 and older.

The average age-adjusted rates were 39% higher for whites and 32% higher for blacks in the five states with the highest death rates compared to the five states with the lowest rates, but they were 27% lower for Hispanics.

Among states with the highest death rates, average age-adjusted death rates were 46% higher for heart disease; 29% higher for cancer; and 39% higher for stroke, compared to the states with the lowest rates. Rates for chronic lower respiratory disease were double and unintentional injuries were nearly double in the highest death rate states compared to the states with the lowest rates.

Fewer and fewer Kentuckians over the past decade have told pollsters that their general health is very good or excellent

The number of Kentucky adults who say they're in very good or excellent health has gradually declined over the last decade, from almost half to only two-fifths.

That was among the findings of the Kentucky Health Issues Poll, co-sponsored by the Foundation for a Healthy Kentucky. "The decline is largely among those adults living on higher incomes, although lower-income Kentucky adults consistently report poorer levels of health," the foundation said in a press release.

"Nationally and in Kentucky, the opioid epidemic continues to take a major toll on health and life expectancy across income levels," said Ben Chandler, president and CEO of the foundation. "Cancer, heart disease and diabetes also shorten lives and reduce quality of life in Kentucky. In many cases, these diseases are completely preventable. But it's often the case that social and financial circumstances make healthier choices far more difficult for people living on low wages."

In the poll, 40 percent of adults said their general health was excellent or very good. That was virtually the same as last year's 39 percent; the poll's error margin is plus or minus 2.5 percentage points. But in 2008, the share reporting excellent or very good health was 49 percent. It declined steadily through 2013, improved a bit through 2016, then fell in 2017.

In that year, 1,468 Kentuckians died of drug overdoses, the foundation noted, adding that "Kentucky also has the highest rates of cancer incidence and deaths, and some of the highest rates of heart disease and diabetes in the country."

The recent decline in reported health status has been steeper among people whose incomes are least double the federal poverty level. In 2008, 66 percent of higher-income people reported very good or excellent health; after six years ranging from 55 to 60 percent, the share has fallen the last three years, hitting a low of 49 percent in 2018.

Among people with incomes below 200 percent of the poverty level, reported health status has fluctuated relatively little; it hit a low of percent in 2017 but rose to 30 percent in 2018. The difference is not statistically significant, because that smaller sample has a larger margin of error.

"We have a dual issues of declining higher-income population health and the inability to improve health among those living on low incomes," Chandler said. "These facts must sharpen the focus of policymakers and health advocates to support what works for these populations. Those include smoke-free and tobacco-free laws and higher tobacco taxes, improving nutrition and increasing physical activity in schools, and reducing the cost and improving access to preventive health screenings and substance use treatment."

Public Health Week is a time to think about immediate challenges and the long-term health of Kentucky and its communities

April 3-9 is National Public Health Week. Why should you care? The reasons are many.

"Have you eaten at a restaurant lately? Did you brush your teeth this morning?  If so, the Department for Public Health has touched your life," state Health Commissioner Hiram Polk writes in a column for Kentucky newspapers. He notes that his agency "doesn’t only inspect the conditions of restaurants you visit, but also worked to make Kentucky the first state to add fluoride to your water to help protect your teeth."

Dr. Hiram Polk

Polk, an internationally renowned surgeon, says his top priority as commissioner is the heroin epidemic, "a crisis unlike any we have ever faced in public health." His agency "has focused on establishing and expanding preventive programs beginning with early childhood education (K-3) stressing the negative consequences of alcohol, drug and tobacco use, and educating our children about the positive outcomes associated with good nutrition and exercise. We have also launched a mobile pharmacy traveling statewide dispensing Narcan, an overdose antidote, and testing Kentuckians for hepatitis C and HIV, both of which are increasing challenges in our communities largely due to drug addiction."

The definition of public health has expanded in recent years, going beyond environmental health and clinical services to a broader concern for the overall health of communities, states and the nation. Kentucky has one of the lowest health rankings among the states, so "We must also tackle the underlying causes of poor health and disease risk," says the University of Kentucky College of Public Health.

"Those causes are rooted in how and where we live, learn, work and play. It’s the child who goes to school hungry and can’t take full advantage of the education that leads to a healthier, more productive adulthood. It’s the low-wage worker who must choose between losing much-needed income and staying home with a sick child. It’s the family that struggles to find nutritious, affordable food anywhere in their community. It’s the student who can’t walk to school because there are no sidewalks. . . . If we partner across public and private sectors to ensure decisions are made with people’s health in mind, we can build healthier communities."

Better-off Kentuckians exercise more; foundation CEO says policymakers can help increase access to exercise venues

By Melissa Patrick
Kentucky Health News

Health status and income matter when it comes to being physically active. Kentucky adults who reporting good health and higher incomes also saying they are more physically active than those reporting fair or poor health or lower incomes, according to the latest Kentucky Health Issues Poll.

"One of the things policy makers and communities can do is make it easier for residents to get exercise in their own neighborhoods," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, a poll sponsor, said in the news release. "The U.S. Office of Disease Prevention and Health Promotion says all adults should avoid inactivity, and those who participate in any amount of physical activity will gain at least some health benefits."

The poll, conducted Sept. 11 through Oct. 19, found that eight in 10 Kentucky adults said they were physically active, with 30 percent of this group reporting they were "very physically active" and 49 percent of them reporting they were "somewhat physically active."

However, these responses varied by health status and income.

Almost nine out of 10 Kentucky adults who reported excellent, very good or good health said they were very or somewhat physically active, compared to only 54 percent of those reporting fair or poor health. And those with higher incomes reported more activity than those with lower incomes, 84 percent and 76 percent respectively.

The survey also asked respondents if their neighborhood is a good place to walk, jog or bike. It found that 76 percent said their neighborhoods were excellent, very good or good for these activities, while 24 percent said their neighborhoods were only fair or poor.

But when asked if they had sidewalks and road shoulders to walk on, the results weren't as positive. Half said their neighborhoods rated excellent, very good or good for this measure and 44 percent said their neighborhoods rated fair or poor.

The survey also asked about safety for exercise; 46 percent said their neighborhoods were safe, 35 percent said they were somewhat safe and 19 percent said their neighborhood was somewhat unsafe or not safe at all for exercise.

Neighborhood exercise conditions also varied by region. Excellent, very good or good neighborhoods for physical activity were reported by 84 percent from Louisville; 81 percent from Lexington; 78 percent from Western Kentucky; 77 percent from Northern Kentucky; and 61 percent from Eastern Kentucky.

Two-thirds of Kentucky adults said increasing their level of exercise would improve their overall health. One-fourth said it would make no difference and 7 percent said it could make their health worse. This attitude varied with education. Those with more education were more likely to say that increased activity would improve their health, compared to those with less education who were more likely to say it would make no difference.

"The foundation is funding demonstration projects to improve neighborhood conditions, such as the health park in Paducah that includes a walking trail, playground and community garden. Kids who learn good physical activity habits will grow up to be healthier adults," Chandler said.

The poll was funded by the foundation and Cincinnati-based Interact for Health. It surveyed a random sample of 1,580 Kentucky adults via landlines and cell phones, and has an error margin of plus or minus 2.5 percentage points.

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.

Survey of low-income Kentuckians, Arkansans suggests expansion of eligibility for Medicaid is making them healthier

A survey of people in Kentucky and other states suggests that the 2014 expansion of the Medicaid program under federal health reform is making them healthier.

The telephone survey of more than 8,500 low-income citizens of Kentucky, Arkansas and Texas was part of a Harvard University study published Monday in the medical journal JAMA Internal Medicine. The researchers found that low-income people in Kentucky and Arkansas, which expanded Medicaid eligibility to 138 percent of the federal poverty level, appear to be healthier than their peers in Texas, which did not expand Medicaid access.

The surveys of Medicaid-eligible people found that those in Arkansas and Kentucky were 4.8 percent more likely than their peers in Texas to say they were in excellent health in 2015.

That difference was bigger than the 2.4 percent difference found in the 2013 and 2014 surveys, which is to be expected because "significant impacts of Medicaid expansion may take several years to unfold," the researchers wrote.

"After two years of coverage expansion in Kentucky and Arkansas, compared with Texas’s non-expansion, there were major improvements in access to primary care and medications, affordability of care, utilization of preventive services, care for chronic conditions, and self-reported quality of care and health." But they cautioned, "It remains to be seen whether the modest changes detected in our study will lead to subsequent improvements in objective measures of population health."

Results from surveys of people with incomes below 138 percent of 
federal poverty line. Arkansas expanded Medicaid through private
insurance. Texas has not expanded it. (JAMA Internal Medicine)

The survey also found that people in Kentucky and Arkansas were more likely to have a doctor and a place to go for care than in Texas, Margot Sanger-Katz reports for The New York Times. They said they were more likely to have their chronic disease treated, and that they were more likely to have received screening for high cholesterol or high blood sugar, markers for heart disease and diabetes.

Measuring whether people are healthier may sound simple, "but it’s actually pretty tough," Sanger-Katz writes. While tests can check for high cholesterol or high blood pressure, "a single test may not tell the whole story. It turns out, however, that when you ask people how healthy they are, they do a pretty good job of telling you."Research shows that people who say they are in poor health are more likely to die soon than those who describe their health as good.

Arkansas' expansion works differently than Kentucky's traditional Medicaid expansion in that it helps low-income residents buy private insurance. Either way, greater access to health insurance seems to be creating positive health outcomes.

"What this means is that it doesn’t matter so much how states expand coverage," Benjamin Sommers, primary author of the study and assistant professor of health policy and economics at Harvard's School of Public Health, said in a news release. "What matters is whether they expand at all."

The researchers were quick to warn that the findings were not necessarily generalizable to other states. "Medicaid programs vary widely across states in terms of physician payment, covered benefits, and other features, which means that our results are in some sense a case study of two specific expansion efforts," they wrote.

Even so, Sommers and the other researchers concluded their study with some advice based on their findings: "As Kentucky and Arkansas reconsider the future of their expansions, our study (along with evidence on the financial benefits to these states of expansion) provides support for staying the course." Gov. Matt Bevin is expected to formally propose changes to the federal government this month.

Poll: Most Kentucky adults, especially the poor, say time, money and motivation make it hard to improve their health status

By Melissa Patrick
Kentucky Health News

Regardless of how Kentucky adults describe their health status, almost two-thirds of them said it would be difficult or very difficult to make positive changes in their health, citing time, money and motivation as their main barriers, according to the latest Kentucky Health Issues Poll.

The survey, conducted Sept. 17 through Oct. 7, found that 43 percent of Kentucky adults said they were in excellent or very good health, 26 percent said they were in good health and 31 percent said they were in fair or poor health. The poll's error margin is plus or minus 2.4 percentage points.

Kentucky ranks 46th in the percentage of adults reporting excellent or very good health. Self-perception of health makes a difference. Research has found a "powerful link" between people's self-reported health status and the predicted length and quality of their lives, says the Institute for Policy Research at the University of Cincinnati, which took the poll.

When asked to name the "most important" thing they could do to improve their health status by one level, the answers varied by the respondents' current health status.

For example, those who reported excellent, very good or good health said they needed to exercise more and improve their diet to improve their health by one status. But those who reported fair or poor health most commonly cited taking care of current health problems and a need for better access to health care as the best ways to improve their health by one status.

"Kentucky adults understand that more exercise and a healthier diet can help them get healthier," stated Susan Zepeda, CEO of the Foundation for a Healthy Kentucky, said in a news release. "We can support better health for all Kentuckians by making changes in our built environment to make exercise easier, supporting access to fruits and vegetables, and continuing to offer all Kentuckians health insurance."

Adults with lower incomes were more likely to report difficulty in making a positive health change, according to the report.

While 65 percent of Kentucky adults said it would be difficult or very difficult to make the health change they had identified, this rate was a bit higher (71 percent) among those who made 200 percent or less of the federal poverty level. Among those who made more than 200 percent of the FPL, 61 percent said so. Only about one-third (32 percent) of Kentucky adults said it would be easy or very easy to make these changes.

The poll is funded by the foundation and Interact for Health, formerly the Health Foundation of Greater Cincinnati. It surveyed a random sample of 1,608 Kentucky adults by both landlines and cell phones.

Ten hospitals and hospital groups to collaborate on improving Kentucky's health, reduce cost of care and share best practices

Ten major hospitals and hospital groups have created the Kentucky Health Collaborative in an effort to reverse the state’s poor health statistics, share best practices and reduce the cost of care through greater operational efficiencies. The 10 and their headquarters towns are:

• Appalachian Regional Healthcare, Lexington
• Baptist Health, Louisville
• Ephraim McDowell Health, Danville
• LifePoint Health, Brentwood, Tenn.
• Norton Healthcare, Louisville
• Owensboro Health, Owensboro
• St. Claire Regional Medical Center, Morehead
• St. Elizabeth Healthcare, Edgewood
• The Medical Center, Bowling Green
• UK HealthCare, Lexington

Appalachian Regional Healthcare will serve as the organization’s headquarters. The collaborative says it is still in early development, and many details are to be finalized, such as the issues it will tackle first. As it develops its structure needed, it will invite other members.

“The Kentucky Health Collaborative has created a governance structure that supports the inclusion and participation of healthcare providers regardless of location within the Commonwealth, size or profit structure, said its executive director, William 'Bill' L. Shepley. “The solutions we expect to develop through the collaborative have worked well for similar networks across the country, and I am honored to be a part of this important process.”

Proposals sought for research of Appalachian 'bright spots' where health is better than socioeconomic factors would indicate

A three-year research project to determine factors that can support a culture of health in Appalachia and whether that knowledge can be translated into actions that address the region's health disparities has released its Request for Proposal to invite proposals from qualified research teams and consultants who would like to work on this project.

The project,“Creating a Culture of Health in Appalachia: Disparities and Bright Spots,” is sponsored by the Appalachian Regional Commission, the Robert Wood Johnson Foundation and the Foundation for a Healthy Kentucky and will run through the end of 2017.

The research for this project will identify Appalachian “bright spots,” where health outcomes are better than would be expected based on unemployment and poverty rates and other community factors, and try to figure out why. Researchesr will also try to determine why health outcomes in some communities are not as good as would be expected.

The request for proposals offers detailed guidelines for submissions, which are due June 8. Applicants are encouraged to register for a webinar, detailed on the RFP, to be held May 7 at 10 a.m. EDT. Click here for more information.

Study of poor but healthy Appalachian counties aims to find community-based approaches to improving the region's health

Though some people equate Appalachian areas with poverty, David Krol seeks to "shine a light" on a different picture—one that reflects "how health can flourish across Appalachia," despite data that confirms economic hardship, Krol writes for the Robert Wood Johnson Foundation.

While Krol was reviewing the Appalachian Regional Commission's county-based economic data, which compares economic indicators like poverty and unemployment rates with national averages and then ranks each county, it occurred to him to overlay this county index with the annual County Health Rankings.

For the most part, Krol said he found what he expected, "that the most economically distressed counties in Appalachia would also be in the lowest quartiles of health outcomes and factors for their state." But some counties that were economically distressed ranked in the top quarter of their state in health factors and outcomes.

"What was it about Wirt County, West Virginia; Pickett County, Tennessee; and Oktibbeha County, Mississippi, that helped them overcome significant economic challenges towards better health outcomes when similarly distressed counties in the same state did not?" he wrote.

The need to know why these "unexpected outliers" occurred has prompted Krol, with the help of the ARC and the Foundation for a Healthy Kentucky, to study how these counties have accomplished this and to look at whether this could be re-created in similar communities.

"This approach is rooted in the belief that communities have the best solutions to the problems they face—as opposed to solutions driven by outside experts," he wrote.

It’s an opportunity to “go beyond the data.. to community conversations about what’s important,” Susan Zepeda, CEO of the foundation, told Krol.

Krol wrote, "Quantitative data can get only get us so far—it’s up to us to ask those critical questions of “Why? How? What can be done? It’s up to us to turn data into action."

U of L plans to create statewide health institute with $4 million, three-year grant from KentuckyOne Health hospital firm

The University of Louisville is creating an institute to improve Kentucky's health through research, education and advocacy of health policies.

KentuckyOne Health is giving the university $4 million over three years to establish the Commonwealth Institute of Kentucky in U of L's School of Public Health and Information Sciences. Dean Craig Blakely said the institute will work in western Louisville but also on statewide issues, focusing on data gathering and analysis.

"Kentucky has the nation's highest rates of cancer deaths and smoking, and ranks among the top for cardiovascular disease, obesity, prescription drug abuse and other health problems," Laura Ungar notes for The Courier-Journal. "And certain neighborhoods, regions and populations suffer disproportionately, with even higher rates."

Appalachian Kentucky has much of what it needs to improve its poor health status, key federal officials agree

By Al Cross
Kentucky Health News

Appalachian Kentucky has the enthusiasm, creativity, people and facilities needed to greatly improve its dismal health status, two high-ranking federal officials said after looking at the problem on a recent tour.

Dr. Thomas Frieden, Rep. Hal Rogers

"I want to stir up our people to get involved in a grass-roots effort," U.S. Rep. Harold "Hal" Rogers, R-Somerset, who hosted Dr. Thomas Frieden, director of the federal Centers for Disease Control and Prevention, on a four-stop tour of his Fifth Congressional District in early August.

Rogers and Frieden were guests on KET's "One to One" Sunday afternoon, in a program recorded right after they returned from their trip, where Frieden said he saw much creativity and enthusiasm.

Using one of Rogers's favorite sayings, Frieden said, "If you plan your work and work your plan, you may very well have tremendous success."

Rogers said what struck him most about the trip was "the infrastructure we already have in place," including hospitals, health departments, doctors and other health providers, and he wants to "talk about enhancing them.

Rogers is in a position to do that with federal money, because he is chairman of the House Appropriations Committee. He is also co-founder, with Democratic Gov. Steve Beshear, of Shaping Our Appalachian Region, an initiative to improve the economy of Eastern Kentucky.

Asked by "One to One" moderator Bill Goodman where the role of government begins and personal responsibility for health begins, Frieden said, in an apparent reference to smoking bans, "You don't want to go to your job and get cancer as a result."

"We don't tell people what to do" at the CDC, he said, but offer communities choices from a list of proven programs. Earlier, he said smoke-free laws not only reduce smoking, but heart attacks among non-smokers.

Rogers said he asked Frieden what one thing he would recommend for improving personal health in the region, and the doctor replied, "Walk."

Frieden said walking is an especially good option for Kentuckians because they have such a beautiful state. However, many rural areas in the state lack sidewalks or other easily accessible places to walk.

"Physical activity is the closest thing we have to a wonder drug" for all sorts of ailments, Frieden said, "but you have to do something you love to do" in order to stick with it. He said it also helps children be good students: "The more physical activity they get, the better their minds will work."

That point was made a few days before the two men's trip, at the Kentucky Summit on Childhood Obesity and Physical Activity at the University of Kentucky.
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Women leading Ky. Health: With less than 16 months left, Haynes tries to 'bake in' health reform, managed care, more

This is the last in a series of stories about four high-ranking female state officials who have guided the state's embrace of the Patient Protection and Affordable Care Act.

By Melissa Patrick
Kentucky Health News

How does a person create lasting change in an ever-changing political environment? “Bake it in,” says Audrey Tayse Haynes.

Secretary Audrey Haynes

As secretary for the Cabinet for Health and Family Services since 2012, Haynes has led the state's efforts to implement the federal health-reform law, dealt with the controlled chaos that was the transition to managed-care Medicaid and faced controversies in the social-services system. Now, with less than 16 months left in Gov. Steve Beshear's administration, she wants to make big improvements in the state’s behavioral-health system.

“We want to get as much (done) as we can get and we want to get it baked in,” Haynes said, “so hopefully the next person that comes will be as enthusiastic about building on the foundation that we have laid.”

Haynes brought more than 25 years of leadership experience to her job, including appointments under three earlier governors. From 1997 to 2001, she was deputy assistant to President Bill Clinton and director of the Office for Women’s Initiatives and Outreach, then special assistant to Vice President Al Gore and chief of staff for Tipper Gore. For the next decade, she was senior vice president and chief government affairs officer for the YMCA of the USA in Washington, D.C.

  

She says her personal style of leadership – “collaboration, inclusion and transparency” – took her staff a while to get used to, but is paying off with results.

“I’m all about forcing people to work together and trying to figure it out because you get a better product,” she said. “We don’t sign things around here unless it’s been vetted through the agency that it is going to impact. It took a while for people to get used to that.”

At her recommendation, Beshear named Carrie Banahan to run the state insurance exchange, Kynect, which has enrolled 521,000 people and become the nation’s model of how to run a successful exchange.

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“We all collaborate and all work together,” Banahan said in a separate interview. “Audrey has comprised a good team in the cabinet and we support her 100 percent.”

“I couldn’t get a better boss,” Public Health Commissioner Stephanie Mayfield said in a separate interview.  “She is genuinely concerned about not just her employees, but the health of the public.”

Haynes said the expanded access to coverage under health reform will improve the health of Kentuckians and the state's health statistics, something employers consider when choosing sites.

“Kentucky has worked so long and hard on building a better, more educated citizenry, so that we (can) recruit more industry and have a stronger economic development base. I believe that is important,” she said. “But equally as important is that we have healthy employees. … I do believe that our state will see many, many benefits from this.”

Health reform has been the most controversial domestic issue of the last few years, but for many people in the health-care industry, there has been more tooth-gnashing over the managed-care Medicaid system that began several months before Haynes became secretary.

Managed care, in which insurance-company subsidiaries get a certain sum per patient and increase their profits by controlling costs, “has not been a walk in the park to implement,” Haynes acknowledged. Providers have complained about slow payment and rejection of claims, and one managed-care firm left Kentucky, saying the state gave it misleading financial information.

She said all involved had to “stop, take a breath and stop screaming long enough to sit down and honestly work through the problems. . . . We have just forced people to the table month in and month out to work out these issues.”

Haynes began collaboration with providers and managed-care firms, and held public forums for all stakeholders to ask questions and get answers. It recently started a second round of forums, and she says things are much calmer now, almost three years after managed care began.

“Our first series of forums for health providers were so successful in opening the lines of communication and making connections that allow us to work better together,” she said in a press release. “We decided to not only repeat but expand the scope of the forums this year, bringing new topics to the forefront like behavioral health, which is particularly timely due to improved access allowed by the Affordable Care Act.”

The next big frontier in managed care is integrating behavioral health with physical health, she said. Noting that more behavioral-health providers are now eligible to receive Medicaid reimbursements, she said that increases accountability toward better outcomes for such patients.

Haynes has little more than a  year left to “bake it in,” because Beshear cannot seek re-election. She acknowledges that the changes in health care are “turning people’s worlds upside down.”

“There are a lot of changes going on, and they are not going to be able to just move on a dime,” she said. “So we have to be able to push, cajole, be patient, teach and then repeat all of that constantly.”

UK president sees the need for 'irrational optimism' and working as a community to improve Kentucky's health

The health and economic issues facing Appalachian Kentucky are daunting, but still worthy of "irrational optimism," as espoused by the head of the federal Centers for Disease Control and Prevention, University of Kentucky President Eli Capilouto says in his most recent short essay.

Dr. Thomas Frieden of the CDC, who toured Eastern Kentucky with Capilouto and U.S. Rep. Hal Rogers last week, had a daily motto for his staff while working in India, a place with even greater challenges: "Irrational optimism is a pre-requisite for sucess," Capilouto writes. He says he saw the power of that in a day-long symposium on health issues sponsored by the Shaping Our Appalachian Region initiative started by Rogers and Gov. Steve Beshear.

"Where so many see problems, Kentuckians see potential," Capilouto writes. "Where others place limits and barriers, Kentuckians see the promise of a brighter tomorrow," especially when they can work together. To illustrate that, he tells the story of a Denver minister he heard on a radio show.

"She was discussing the idea of what it means to be human; what it means to be part of a community," Capilouto writes. "The minister said she disagreed with the notion that God will never give you more than you can handle. 'God,' she said, 'will never give you more than your community can bear or you as a member of a community.' The idea, of course, is that we all need each other. And we all have responsibilities to each other. That’s what it means to be part of — and partners with — community." (Read more)

Beshear lays out plan for improving Kentucky's health, with specific goals and largely administrative strategies

By Al Cross
Kentucky Health News

Gov. Steve Beshear set seven specific, numerical goals Thursday for improving Kentucky's "dismal" health status, which he said is hurting the state's education, productivity, attractiveness to employers, state revenues "and our very quality of life."

Beshear, whose term ends in early December 2015, set the goals to be met by Jan. 1, 2019 and said he would hold his appointees "accountable for measurable, reasonable progress." The goals of the program, dubbed "kyhealthnow," are:

• Health insurance: Reduce the share rate of uninsured Kentuckians to less than 5 percent, through Kynect, the insurance exchange Beshear created under federal health reform.

• Smoking: Reduce Kentucky’s smoking rate, now the highest in the nation at 28.3 percent of adults, by 10 percent. The strategies include increasing the use of smoking-cessation therapy, now covered under Medicaid, by half; and two major legislative items, a statewide smoking ban and a higher cigarette tax, for which Beshear said he would keep pushing in next year's legislative session if not passed in the current one. "Smoking is the single biggest factor negatively affecting the overall health of Kentuckians," he said.

• Obesity: Reduce the rate by 10 percent through 13 separate strategies, including measures to encourage physical activity, using Kynect to double the number of enrollees in the state diabetes prevention program, and partnering with school districts to increase the number that collect and report students' body-mass indexes. Kentucky is the fifth worse state for physical activity among adults.

• Cancer: Reduce cancer deaths by 10 percent, largely through more screening. Kentucky has the nation's highest cancer death rate.

• Cardiovascular Disease: Reduce cardiovascular deaths by 10 percent, with measures such as more smoking cessation and aspirin therapy. Kentucky has the nation's third-highest death rate from diseases of the heart and circulatory system.

• Dental Decay: Reduce the percentage of children with untreated dental decay by 25 percent, and increase adult dental visits by 10 percent. The strategies include public-private partnerships to see that three-fourths of the state's grade schoolers get fluoride varnish treatments. "the poor dental health of Kentuckians has not only subjected Kentucky to ridicule, but has detrimental impacts on children, the workforce and families," Beshear said.

• Drug Addiction: Reduce deaths from drug overdose by 25 percent, and reduce the average number of poor mental health days of Kentuckians by 25 percent. The strategies include a "Good Samaritan Law" for people seeking drug treatment for themselves or others, and 50-percent increases in the availability of substance-abuse treatment. Kentucky ranks third in the nation in drug overdoses.

From left: Cabinet Secretary Mary Lassiter, Justice Secretary
J. Michael Brown, Beshear, Abramson, Haynes, Mayfield

Increasing drug treatment would cost money, but Beshear said the state, nonprofits and the private sector can make most efforts "with very little cost to anybody." For a complete list of the goals and strategies, click here.

Beshear named Lt. Gov. Jerry Abramson to head a working group that will push the goals, with Public Health Commissioner Dr. Stephanie Mayfield Gibson as vice chairman. The group will contain leaders from every state cabinet and will seek advice and partnerships from agencies and institutions outside state government.

Health and Family Services Secretary Audrey Haynes acknowledged that improving Kentucky's health status requires individuals to change their unhealthy behaviors, but said the greater availability of health insurance through Medicaid and subsidized insurance gives them more opportunity to do that. "Now we just have to lead them to the water and make them drink," she said, adding later, "We have to put peer pressure on each other," and health-care providers "have to become educators, more than ever."

Beshear discounted an Oregon study that found expanding Medicaid didn't improve the health of new beneficiaries, saying it only covered two years. "We all know this is a long-term process," he said. "We need to look 10, 15 years out. . . . This is for the next generation." For a story and six-minute video from Nick Storm of Time Warner Cable's cn|2, click here.

Kentucky Chamber of Commerce President Dave Adkisson attended the announcement and distributed a written endorsement saying, "The business community has grown increasingly troubled by the impact of our state's poor health status on workforce productivity, absenteeism, health insurance rates and tax bills."

The Foundation for a Healthy Kentucky said it sees in Beshear's plan "a mix of winnable battles – and a commitment to measuring impact – that together will help make Kentucky healthier and more competitive.  Decreasing smoking and the number of families living without health insurance, and increasing the numbers of Kentuckians with ready access to healthy foods and safe places for active living, in the near term is likely to have the payoff we all seek in reducing preventable disease and death from cancer and heart problems in years to come."

By more than 2-1, Kentuckians support a statewide ban on smoking in most public places, including restaurants and bars

By more than 2 to 1, the heaviest margin ever, Kentucky adults favor a state law to ban smoking in most public places, including restaurants and bars, according to the latest public poll on the issue.

A statewide smoking ban was favored by 65 percent and opposed by 29 percent in the latest Kentucky Health Issues Poll, conducted Oct. 25 through Nov. 26 by the Institute for Policy Research at the University of Cincinnati. In fall 2011, 59 percent favored it and 38 percent opposed it. The polls' error margin is plus or mimus 2.3 percenatge points

The largest shifts in opinion occurred among Democrats and independents, and in Western Kentucky, Northern Kentucky and the Lexington area. "It's not a partisan issue. It's become a health issue," said Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which sponsored the poll with Interact for Health, formerly the Health Foundation of Greater Cincinnati.

In the latest poll, support for a smoking ban jumped 10 points among Democrats, to 69 percent, while Republicans stayed steady at 64 percent. But the larger error margins for those smaller samples mean that there is no statistical difference between the parties. Among independents, 57 percent supported the proposed law, up from 44 percent the year before.

Such shifts might indicate that a smoking ban could get farther in the General Assembly than in the past two sessions, when it got out of a House committee but did not receive a floor vote. So could the geographic shifts in opinion, especially in Western Kentucky, where local smoking bans are less common than in the state's more heavily populated areas. The legislative session begins Tuesday, Jan. 7.

In the 42 counties the poll defines as Western Kentucky, which had been the region least supportive of a ban, the poll found that 65 percent of adults now favor it, while only 30 percent oppose it. A year earlier, the split was 53-44, and the error margin of plus or minus 5.48 percentage points for that small sample made it a statistical tie.

Similar shifts were seen in Northern Kentucky, where 66 percent now favor a statewide ban, and in Lexington, where it is backed by 71 percent, more than in any other geographic area. Lexington has had a local ban for 10 years, and the University of Kentucky bans smoking anywhere on campus.

The region least supportive of a ban is now Appalachian Kentucky, but even there, 62 percent favor it while 34 percent oppose it. The region showed the smallest change in opinion from the year before, when the split was 58-40. Until the latest poll, Appalachian opinion on the issue had been virtually the same as statewide opinion. The poll defines Appalachian Kentucky as the 46 counties in the Big Sandy, Buffalo Trace, Cumberland Valley, Fivco, Gateway, Kentucky River and Lake Cumberland area development districts.

The Appalachian results may reflect the fact that the region is where residents are most likely to be smokers. The poll found little if any change among smokers' support for a ban, rising one point to 38 percent. Among former smokers, it rose to 72 percent; among those who said they had never smoked, there was a 9-point increase, to 84 percent. One-third of those surveyed said they were smokers, slightly higher than more comprehensive surveys generally show.

Zepeda, who regularly tracks health issues and discussions of them, said she and the foundation staff were surprised at the large overall increase in support for the proposed law. She said it might have been cause in part by an increased "understanding about the inability to pick where you work," especially in a state where unemployment is still above 8 percent. She said someone who opens a restaurant door and smells cigarette smoke can go to another restaurant much more easily than workers in smoky workplaces can find a smoke-free place to work.

The foundation noted in its press release that the federal Centers for Disease Control and Prevention said in 2006 that no level of secondhand smoke is safe, and recommended that all indoor smoking be eliminated.

While the foundation does not lobby and generally doesn't express opinions on pending legislation, Zepeda said, "We do feel the data are compelling, that not smoking is better for Kentuckians, and not breathing other people's smoke is better for Kentuckians. . . . All told, it would be good for the health of Kentucky if there were a statewide smoke-free law or regulation."

Kentucky leads the nation in percentage of adults and children who smoke, and in lung cancer and deaths from it. Asked if cigarettes are the No. 1 factor in the state's poor health status, Zepeda said, "It is a strong contributing factor. I think nutrition and [lack of] physical activity are up there, as well."

Business owners who oppose local smoking ordinances or health-board regulations, because they fear losing customers to adjoining areas without such bans, might prefer a statewide law, Zepeda said. The Kentucky Chamber of Commerce favors it, mainly as a way to reduce employers' health costs.

Zepeda said that as federal health reform uses tax dollars to bring health coverage to more people, more taxpayers may see the benefits of measures to discourage smoking. Kentucky is among the states expanding the Medicaid program to households with incomes up to 138 percent of the federal poverty line; the federal government will pay the entire cost of that until 2017, when the state will start paying increasing shares, topping out at 10 percent in 2020.

Here's an interview between Zepeda and Ryan Alessi of cn|2's "Pure Politics:"