Kentucky Hospital Association says its annual survey shows state continues to have an 'acute shortage' of health care workers

Kentucky Hospital Association graph; to enlarge, click on ot; to download, right-click.

By Melissa Patrick
Kentucky Health News

The Kentucky Hospital Association's annual Workforce Survey Report says Kentucky suffers from an "acute shortage" of health care workers, with nearly 13,000 job vacancies in hospitals across the state at the end of 2022.

“While the shortage of health-care workers is nationwide, it has hit the commonwealth especially hard, and KHA is working with multiple partners to find ways to address the challenges,” KHA President and Chief Executive Officer Nancy Galvagni said in a news release.

The KHA Workforce Survey Report provides an in-depth look at the non-physician hospital workforce in Kentucky. It found that Kentucky had a 15% vacancy rate among that workforce in 2022.

Of the 13,000 open jobs, nearly 5,000 were openings for registered nurses and nearly 300 for licensed practical nurses, teh survey found. And, there are over 1,000 open slots for nursing aides. 

For the first time, hospital-employed paramedics, EMTs and other EMS personnel are included in the report. They had the highest vacancy rate among non-nursing occupations (19.2%), followed by respiratory therapists (15%) and behavioral-health professionals (12%). 

Kentucky Hospital Association charts; click to enlarge

The survey report shows vacancy rates differ from region to region with only two area-development districts, Green River and Fivco in the northeast, having vacancy rates below 10% for registered nurses and all hospital employees. The Kentucky River ADD, in the southeast, has the highest vacancy rate, with nearly 24% of its hospital workforce and 34% of its RN positions vacant.

The survey shows that the shortage of registered nurses is the most pronounced, with four AD districts having registered-nurse vacancies above 20 percent – Barren River (21.2%), Lincoln Trail (22.3%), Buffalo Trace (22.4%), and Bluegrass (23.7%). Vacancies employee vacancies above 20 percent, Kentucky River (23.7 percent).

The report notes that the level of vacancies means wait times are longer for those seeking treatment.  KHA says it is working with hospitals to actively convene partners to address these provider shortages, including the Kentucky Chamber of Commerce, the Council on Postsecondary Education and the Kentucky Community and Technical College System, along with nurses and hospital administrators. 

“Our primary objectives are to expand Kentucky’s health care workforce pipeline, remove barriers to health care education, retain the current health care workforce, and redesign models of care,” Russell F. Cox, president and chief executive officer of Norton Healthcare and chair of the KHA Workforce Committee, said in the release. “Through extensive public and private sector collaboration, we are poised to help more Kentuckians attain rewarding, long-term careers in health care while improving the health of our communities.”

The news release notes that the work of this committee is crucial because a new Global Data study, commissioned by KHA and the Kentucky Board of Nursing, shows there will be a shortfall of 6,000 RNs by 2035, which is about the same as it is today. 

90% of for-profit nursing homes would need more staff to meet proposed rules; 60% of others would, KFF Health News estimates

KFF Health News graph; individual estimates for staffing by RNs and aides are in the story.

Kentucky Health News

For-profit nursing homes would have to hire more staff to meet proposed federal rules than other nursing homes would, according to an analysis by KFF Health News, a service of the Kaiser Family Foundation.

"90% of for-profit facilities would need to hire additional nursing staff, compared with 60% of non-profit and government facilities," says the analysis by Alice Burns, Priya Chidambaram, Tricia Neuman and Robin Rudowitz.

In Kentucky, about two-thirds of nursing homes are for profit, and only 21% of all homes meet the proposed standard, which is about the same as the national figure of 19%, KFF Health News estimates.

The Centers for Medicare and Medicaid Services has proposed that nursing homes employ registared nurses for at least 0.55 hours per resident per day, and nurses' aides for at least 2.45 hours per resident per day. The rule would also require facilities to have an RN working at all times.

"CMS is seeking comment on several alternatives to the proposed rule, one of which would require facilities to comply with requirements that were adjusted to reflect the health and frailty of nursing facility residents," KFF Health News notes. "Assuming this alternative was implemented using CMS’ existing approach for adjusting staff hours for resident health and frailty, virtually all facilities would need to hire new staff to meet the requirements."

Nursing homes say some of them might have to go out of business because they already have big problems finding enough nurses and nurses' aides. To address that concern, the rules would be phased in, with some differences for rural and urban nursing facilities.

The first phase, starting 60 days after publication of the final rule, would require facilities to "assess the needs of each resident, include input from nursing facility staff and residents’ families or legal representatives, and develop a plan to meet required staffing levels given residents’ needs," KFF notes.

Two years after publication, urban nursing homes would need round-the-clock RNs. For rural nursing homes, that would occur three years after publication. After that, the rules for number of nursing hours per resident day would kick in.

The proposed rule would allow nursing hoems to have less staffing if they are "at least 20 miles from the nearest nursing facility, or in an area with workforce unavailability (defined as having a provider to population ratio that is at least 20% lower than the national average)," KFF notes. "Nursing facilities would also have to demonstrate good faith efforts to hire and retain staff and a financial commitment to staffing by reporting the total amount of money spent on direct care staff." They could not get such exemptions "if they had any staffing-related violations" or had been designated as a Special Focus Facility "with a history of serious quality issues."

KFF explains, "Nearly half of facilities meet the RN requirement (52%) but only 28% meet the nurse aide requirement. . . . When looking at ownership of facilities that meet the RN requirement, a larger share of non-profit facilities would meet the 0.55 standard than for-profit and government facilities (75%, 44%, and 61%, respectively). When looking at nurse aides, about half of non-profit and government facilities meet the minimum staffing levels, compared with only 20% of for-profit facilities."

However, "If the proposed staffing levels were enforced after accounting for resident health and frailty, virtually no nursing facilities would meet the requirements in the proposed rule," KFF estimates.

And what about the workforce shortage? "As of June 2023, employment levels were still more than 11% below pre-pandemic levels for workers in skilled nursing care facilities and 3% below pre-pandemic levels for workers in elderly care facilities," KFF reports. "Although fewer facilities would need to hire new RNs, those that do may find it difficult to compete with hospitals, many of which are also trying to increase the number of RNs they employ. To the extent that many nursing facilities receive hardship exemptions on account of workforce shortages, the effects of the proposed rule on minimum staffing levels will be muted."

CMS estimates that the proposed rules would cost nursing homes $40 billion in the first 10 years after the final rule takes effect. "Such costs are likely to be passed on to public and private payers for nursing facility services, including residents and their family members who paid $45 billion in out-of-pocket costs for care in nursing homes" and other long-term care in 2020. "Medicaid spent nearly $53 billion in that year, about twice the amount ($26 billion) that traditional Medicare spent on skilled nursing facilities in 2020, and although Medicaid financing is shared by the state and federal governments, all states except for Vermont must meet balanced budget requirements."

Overdose deaths in Ky. workplaces tripled in 2019-2021; in the latter year they were the 2nd leading cause of occupational fatality

Graph by Kentucky Injury Prevention Research Center

By Melissa Patrick

Kentucky Health News

Drug-overdose deaths in Kentucky workplaces tripled from 2019 to 2021, according to the latest annual report from the Kentucky Fatality Assessment and Control Evaluation program.

The program, part of the Kentucky Injury Prevention and Research Center, found that from 2017 to 2021, the state had 47 overdose fatalities in the workplace, reaching its highest number ever of 18 fatalities in 2021. That was a 260 percent increase from 2017.

Of the 96 occupational fatalities recorded in Kentucky in 2021, drug-overdose deaths accounted for 19%, an increase from 13% in 2020 and 8% in 2019. That put overdose deaths second to motor-vehicle crashes, which were 29% of the total. In third place (17%) were "struck by" and "striking against" injuries, forcible contact or impact with an object that creates an injury.

Most of the occupational drug-overdose deaths in 2017-2021 occurred in the trade, transportation and utilities industries (38%), followed by manufacturing (19%), construction (19%) and the leisure and hospitality industry (11%). The remaining 13% took place in services and public administration.

The report notes that all of the occupational overdose deaths in the leisure and hospitality industries happened in 2020 and 2021.

It also points to the jump of occupational-overdose deaths in Jefferson County. In 2021, seven of the state's occupational overdose deaths, nearly 40% of the total, occurred in Jefferson County. That was one short of the total for the previous four years combined.

Bill would address health-care workforce shortage with public-private fund to help Kentuckians enter health-related professions

By Melissa Patrick
Kentucky Health News

In response to Kentucky's health-care workforce shortages, the legislature has sent Gov. Andy Beshear a bill to create a fund with private and public money to help more Kentuckians pursue health-related careers.

Rep. Ken Fleming

"This is a growing crisis that threatens not only to burden families and providers, but may jeopardize the very availability of critical health care services across the country," Rep. Ken Fleming, R-Louisville, said in presenting the bill to the House March 8. 

The need for health-care workers in Kentucky is well-documented. 

The Kentucky Hospital Association's 2022 Workforce Survey Report cited 13,423 total vacancies in Kentucky hospitals, including 5,391 for RNs and LPNs combined, or more than one in five nursing positions. Other top vacancies included respiratory therapists (17.7%), laboratory staff (14.2%), environmental services (13.7%) and social workers (13.7%).

The report says urban hospitals had larger vacancy rates than rural hospitals, at 18.3% and 13.8% respectively, but both rates are "unsustainable."

The Eastern Kentucky Healthcare Action Plan by Shaping Our Appalachian Region says the region’s turnover rates in vital health-care roles are statistically at or above the national turnover rate of 19.5%. In 2021 it was 24.6%. Further, it says healthcare jobs are responsible for 17.6% of Eastern Kentucky's economy, more than any other industry in the region, and that thousands of jobs remain unfilled.

Fleming's House Bill 200 aims to address this shortage by creating the Kentucky Health Care Workforce Investment Fund. It would use public and private money to increase scholarship opportunities.

Fleming told the House that this "innovative and creative" approach "puts a jetpack on the health-care training pipeline." 

The fund will be administered by the Council on Postsecondary Education, with 65% of it to be used for educational scholarships and 35% to be used to incentivize universities and training programs. 

Money from the fund can be used for a wide range of certified and licensed health-care professions, including nurses, mental-health professionals and emergency medical professionals, to name a few. 

The bill says the money can be used to "improve racial and ethnic diversity within a specific designated healthcare credential."

In abortion ruling's wake, Senate GOP caucus chair says Ky. must see to adoption and human services, protect jobs in pregnancy

Senate Majority Caucus Chair Julie Raque Adams (LRC photo)

By Al Cross

Kentucky Health News

The U.S. Supreme Court's reversal of its Roe v. Wade decision means more work for the Kentucky General Assembly, a leading state senator said in a Lexington television interview broadcast Sunday.

"That issue will probably take up a lot of space in this upcoming session," Majority Caucus Chair Julie Raque Adams, a Louisville Republican, told Bill Bryant on WKYT-TV's "Kentucky Newsmakers."

"It's important for the legislature to make sure we have adequate resources for adoption care," that the state is "fully implementing" the two-year-old Pregnancy Protection Act for workers and "make sure that the human services end of things are funded so we are helping families and helping women," she said.

The extent of activity on the issue will likely depend on what the courts do between now and convening of the session in January, Raque Adams said: "We'll probably take our lead from the courts."

A Louisville judge is considering a lawsuit arguing that the state constitution's implied grant of privacy rights, which the state Supreme Court extended to strike down a law banning sexual relations between people of the same sex, creates a privacy right to abortion. Whatever his ruling, an appeal is certain.

Not so certain is whether, during appeal, courts will continue to block state laws that ban abortion after the sixth week of pregnancy and ban all abortions except those needed to save the woman's life or keep her from becoming disabled. The latter law was written to take effect if Roe v. Wade was overturned. 

Raque Adams noted that the Nov. 8 ballot includes a constitutional amendment that would negate the lawsuit's argument by saying that the state constitution does not create a right to abortion or government funding of it. She said she is telling people on both sides of the issue that debating the amendment is "a great way" for people to engage with the issue.

Democratic Gov. Andy Beshear has said he opposes the amendment, calling it "extreme" because it has no exceptions for rape or incest. Asked if she supports the amendment, Raque Adams did not answer directly: "Yes, I voted to put that on the ballot."

Asked if the legislature might try to ban abortion medication, the most common method of abortion, or restrict Kentuckians' travel to states with less restrictive abortion laws, Raque Adams said she had not heard such legislation mentioned for Kentucky.

State Labor Cabinet reminds employers to protect employees as heat indexes hit triple digits and a hot workweek is forecast

CDC photo

As heat indexes went well into the triple digits Monday and weather forecasts predicted a hot workweek, the state Labor Cabinet reminded employers to protect employees working in hot conditions.

Labor Secretary Jamie Link urged employers to "establish a heat illness prevention plan, closely monitor workers in hot indoor and outdoor environments, and learn how to recognize and treat various heat-related illnesses," a cabinet press release said.

“Employers are responsible for providing safe workplaces free of known hazards, and that includes extreme heat conditions,” Link said in the release. “Asking workers to perform physically exhausting work in dangerously hot conditions without providing breaks, water and shade can result in serious illness and even death.”

The federal Occupational Safety and Health Administration recommends regular water, rest and shade breaks for those working in hot environments, outdoors or indoors. OSHA and the National Institute for Occupational Safety and Health have free mobile application for Android and iPhone users that provides real-time heat index information and hourly forecasts by location, as well as occupational safety guidance and health recommendations. The tool can be found on Google Play and in Apple’s App Store.

Kentucky's program provides free, confidential heat exposure assessments by request, and offers a Heat Stress Awareness training module on its website. The cabinet is offering a class on heat stress during a population center training event June 21-24 in Frankfort.

Ky. OSHA complaints rose 45% in 2020, partly due to pandemic; issues are likely to linger as workplaces try to get back to normal

Courier Journal graph, adapted by Kentucky Health News

Kentucky workers filed 45 percent more occupational safety and health complaints in 2020 than in 2019, but only 8 percent of them have been investigated, reports Matt Mencarini of the Courier Journal.

The increase could have had causes other than the pandemic, since the volume of complaints can be cyclical, the state Labor Cabinet told Mencarini. But he cites examples, such as a November complaint against the Kroger Distribution Center in Louisville, alleging that employees had Covid-19 and managers were not informing others about it.

The state's low investigation is actually above the national average, Mencarini reports. "Across the U.S., complaint investigations decreased dramatically during the pandemic," he writes. "Critics for years have derided weak worker safety laws and enforcement, decrying dwindling budgets and staffs in worker safety agencies. The pandemic only exacerbated the problem, they say."

Bill Londrigan, executive director of the state AFL-CIO, told Mencarini, "There needs to be some sort of recognition that even though the rates of transmission and death from Covid have decreased due to the increase in the vaccination rates, that certainly it is not in the rearview mirror. Protections should still be in place."

"Many of the complaints lodged in 2021 suggested the national polarization around masks extended to the workplace," Mencarini reports. "As Covid rates drop and more people return to workplaces, new challenges are arising." Londrigan told him that some workplaces shouldn't abandon mask-wearing, though "no one really likes it."

Kentucky's covid-19 report has good and bad news in it today; Beshear says he will talk about schools tomorrow

Kentucky Health News chart; daily numbers are often adjusted slightly after initial report.

By Melissa Patrick
Kentucky Health News

The good news is that Kentucky had fewer coronavirus cases in the reporting week that ended Sunday, Gov. Andy Beshear said. The bad news, he said, is that the percentage of Kentuckians testing positive for the virus keeps rising. 

Gov. Andy Beshear in his Facebook video Sunday

"We're ending the week with about 300-and-change less cases that we had last week," Beshear said in a Facebook post on Sunday's covid-19 report. "That's directly attributable to people wearing their facial coverings or mask. Please, keep it up, wear them even more, especially when you are inside."

Then he said, "On the bad side, our positivity rate, which won't be official until tomorrow for this week, will be higher, meaning that the virus continues to spread aggressively." 

Saturday's positive test rate was 6.02 percent, the highest it's been since May, when the state tested the entire Green River Correctional Complex in Central City. Health experts consider rates above 5% cause for concern. 

Beshear reported 425 new cases of the virus on Sunday, about 375 fewer than yesterday, but higher than a typical report on a Sunday, when fewer testing labs report to the state. The seven-day rolling average fell a bit to 555; it has been between 528 and 592 for the past week. The three-day average is 600.

Beshear pointed out that nine counties had 10 or more new cases Sunday, and Health Commissioner Steven Stack said all but five counties saw rising case counts last week. 

Jefferson County had nearly 32% of Sunday's new cases, at 135. Other counties with more than 10 were Fayette, 47; Pulaski and Taylor, with 19 each; Hardin and Madison, with 13 each; Casey and Warren, with 12 each; and Wayne, 11. 

“Covid-19 is still out there and it’s still a threat,” Stack said in a news release. "We are encouraged, though, by the many Kentuckians taking this seriously and taking steps to keep themselves and others safer, including wearing a mask.”

The state's top doctor called on Kentuckians to continue to do the things that are known to mitigate the risk of getting or spreading the virus.

“Every time we take steps, such as wearing masks and social distancing, it impacts how many Kentuckians will test positive, how many businesses, schools and other places where we gather can remain open, and how many Kentuckians will get hurt,” Stack said. 

He also reminded Kentuckians to limit their outings and to make sure to wear a mask, social distance and practice good hand hygiene when you do go out: “When you and your household members leave your home, be aware that it increases your risk of exposure.”

In addition, he called on Kentuckians to practice good, old-fashioned public-health precautions, offering a longer list than usual:

“Continue to wear a mask. When possible, walk or bike to your destination or take your own vehicle. Avoid interacting closely with people and unnecessarily touching things. Keep disinfecting wipes or hand sanitizer with you. Wash your hands frequently. If you sneeze, sneeze into your elbow. If you sneeze into a cloth mask, wash your mask when you get home.” 

The state reported one more covid-19 death Sunday, raising its toll to 773. The fatality was s a 71-year-old man from Pulaski County. The daily report did not provide today's covid-19 hospitalization data. 

Beshear said he would talk Monday about a possible recommendation about schools at tomorrow's 4 p.m. press conference.

"We certainly need to get control of this virus to protect our teachers and our students," he said. 

Beshear said Wednesday that a continued high positive-test rate might prompt him to recommend again that in-person schooling be delayed. On July 27, he recommended that it not begin until the third week of August, but those decisions are up to local school officials. 

The Kentucky Education Association, the statewide teachers' union and a major Beshear ally, said Friday, "In-person instruction should not resume until, at a minimum, the infection rate in Kentucky statewide and the infection in the county in which the school district is located both fall below 4% and both remain below 4% for 21 consecutive days as measured by a 7-day rolling average."

Grayson County newspapers introduce health department's new public health director, who says he's going after human trafficking

Grayson County Public Health Director Joshua Embry
(Photo by Matt Lasley, Grayson County News-Gazette)

By Al Cross
Kentucky Health News

LEITCHFIELD, Ky. – Health departments in Kentucky usually operate in the background, or under the radar of local news organizations, unless a health issue arises. But their work is important, so they deserve more regular attention, and both weekly newspapers in Grayson County did that when it got a new public health director.

Some residents of the west-central Kentucky county may have been startled when they read a headline in the Grayson County News-Gazette saying that Joshua Embry was going to "address human trafficking." He told reporter Matt Lasley, "Based on our clinic services, we know for a fact it is happening in our community. . . It's definitely happening in small, rural towns."

"According to Embry, human trafficking is not solely related to sex, it also includes human labor, and can be drug-related as well," Lasley reports. "In many instances, people are brought into the country and forced to provide unpaid labor to work off a debt to the person who brought them here."

Also, "Underage children can be victims of human trafficking without ever leaving their homes, by being deceived into sharing explicit images of themselves with people online. These images are then widespread, which falls under the umbrella of human trafficking, health department officials say."

January is Human Trafficking Awareness Month, and Embry "is beginning an awareness campaign aimed at educating the community on the issue and how to address it and report it," Lasley writes.

The front-page story in the county's other weekly, The Record, briefly mentioned human trafficking and was more general, reminding readers of the health department's wide range of services and responsibilities, which include "grief counseling services for families who've lost a child."

"People hear 'health department' and they automatically think STD tests" for sexually transmitted diseases, Embry told The Record's Rebecca Morris. "I want to be able to educate the community on all the programs we have. A lot of people just don't understand the great resource the health department is."

Embry, 32, began work last month after almost seven years at Breckinridge Health, which operates Breckinridge Memorial Hospital in Hardinsburg. After a brief teaching career, he started as an emergency-room admittance clerk and ended as coordinator of compliance, emergency preparedness and safety. He told Morris that health care is a "field you definitely have to be called to."

One could say that about the weekly newspaper business, too. I was editor of the News-Gazette (and general manager of a predecessor, The Leitchfield Gazette) before the Louisville Courier Journal hired me away in 1978. One of my successors as editor, Jenny Searcy, started The Record a few years later.

Grayson may be the only county in the U.S. with weekly newspapers operated by competing chains, which usually don't buy papers with less than $1 million in annual revenue, and certainly not in competitive markets. But Landmark Community Newspapers of Shelbyville bought The Record to give advertisers in its Elizabethtown daily, The News-Enterprise, an opportunity to buy combination ads. It ran a circulation campaign, managed by Searcy, that won it the local circulation lead and thus the public-notice ads. The News-Gazette went through several owners and is now owned by Paxton Media Group of Paducah, which bought in a 2017 package deal with two other nearby papers and moved it from twice-weekly to weekly publication. The county of 27,000 also has an AM-FM radio station with an active news department, WMTL-WKHG in Leitchfield, a town of about 7,000.

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

By Melissa Patrick
Kentucky Health News

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

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

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

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

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

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

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

The study findings

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

State says number of Kentuckians getting disability benefits has exploded since 1980; rates are highest in Eastern Kentucky

By Melissa Patrick and Al Cross
Kentucky Health News

The number of Kentucky adults and children receiving disability benefits has increased in "staggering proportions," since 1980, and the Social Security disability system needs "radical reform, says a report from the state Disability Determination Services agency.

The report says that from 1980 to 2015, while Kentucky’s population grew by 21 percent, its combined disability enrollment grew by 249 percent. In the same 35 years, the national increase was 211 percent, so Kentucky's rolls were growing faster than the nation's.

By 2015, the report says, 11.2 percent of Kentuckians were receiving some form of disability benefit payment, higher than any state but West Virginia. It has held second place since the ranking were compiled, the report says.

Disability is prevalent in Central Appalachia. Twelve adjoining Eastern Kentucky counties had the state's top shares of the population receiving disability benefits in 2015, the report says: Wolfe, 24.9 percent; Owsley, 24.6; Breathitt, 23.8; Clay, 22.9; Magoffin, 22.3; Floyd, 21; Lee, 20.2; Leslie, 20; Martin, 19.3; Harlan, 18.9; Perry, 18.8; and Bell, 18.4 percent.

The report said that as the number of disability enrollees increased, so did prescriptions for controlled substances. Counties in the top 12 of disability and opioid use in 2015 (in alphabetical order) were Bell, Breathitt, Clay, Floyd, Lee, Leslie, Owsley, Perry and Wolfe.

Owsley County was in the top 12 for psychotropic drugs such as Xanax in 2001, 2005, 2010 and 2015, all the years surveyed for the report. Owsley and Clay counties were in the Top 12 for disability and opioids per person in 2001, 2005 and 2010.

Opioid prescriptions among those receiving disability payments rose from 48 doses per person in 2000 to 147 doses in 2015, an increase of 210 percent. Nationally, the use of opioids increased due to a greater emphasis on the treatment of pain and aggressive marketing by opioid manufacturers, especially in Central Appalachia, which ranks high in the share of the population on disability.

Central Appalachia has a relatively large percentage of workers who did not graduate from high school, worked in manual labor, and when injured found it difficult to get other work. Most of Kentucky's disability recipients have diseases of the musculoskeletal system and connective tissue (33.4 percent) or a mental disorder (32.8 percent), the report says. Other conditions included diseases of the circulatory, nervous and respiratory systems. National figures are similar.

Most of the state's disabled children (70 percent) are enrolled for mental disorders. Those who got Supplemental Security Income benefits or were in Medicaid had a 168 percent increase in psychotropic prescriptions from 2000 to 2015, from 273 doses per person to 457 doses.

The report's main author, Bryan Hubbard, acting commissioner of the state Department for Income Support, said in a news release, “The explosive growth of benefit dependence over the past 35 years has been fueled by a multitude of factors which are completely unrelated to the mitigation or treatment of hardship borne of genuine disability.”

A 2014 Center on Budget and Policy Priorities report said the number of disabled workers collecting monthly benefits tripled from 1980 to 2013, from 2.9 million to 8.9 million. It cited four factors for most of the increase: population growth, an aging population; growth in women's labor-force participation; and later retirements. It also offers results from several other studies with similar conclusions.

Adapted chart from Kentucky Center for Economic Policy

The liberal-leaning Kentucky Center for Economic Policy replied to the state report with similar points, noting that the share of Kentuckians aged 50 to 64 has increased by half, from 13.6 percent in 1990 to 20.2 percent in 2016, and that three-fourths of Kentuckians on disability are 50 or older. Now that baby boomers are retiring, Kentucky's disability enrollment "has dropped every year since 2013."

The state report suggests another reason for the growth in disability benefits. It says the federal Social Security Administration's culture is an obstacle to change because it is motivated to protect and expand enrollment for disability benefits in order to maintain its budget. The report says SSA administrative law judges award disability benefits "at rates substantially higher" than the state's Disability Determination Services, and it gives a list of the judges and their award rates.

The report calls for "radical reform," including making it a requirement that "objective medical evidence" be used to determine eligibility; removing all "subjective non-severe conditions" from the list of eligible conditions; and allowing the judges only to correct errors by state disability determiners. The report is available in PDF, with an accompanying PowerPoint presentation.

The report has language remarkable for a government document. After identifying politicians, lawyers, judges and doctors as obstacles to change, it says "There are individuals and institutions which exploit and derive power from an ever-expanding dependency class populated by desperate but functional people. These actors promote a dependence system which often functions as an apparatus of state sponsored suicide – anesthetizing and euthanizing its victims – a disproportionate number of whom are either young, poor, or both."

The Kentucky Center for Economic Policy said in its reply, "Concerns that DI in Kentucky is being overused reflect a fundamental misunderstanding about the program. It is actually very difficult to be approved for DI — in Kentucky as well as nationally. . . . Fewer than one in four applicants for DI receive it after an initial request in Kentucky. Ultimately, after two rounds of appeals, a total of 28.3 percent of Kentucky applicants receive DI benefits, which is below the net approval rate nationally of 32.1 percent in 2015." And it called the benefits "modest," saying "The median monthly benefit for a DI recipient in Kentucky was $1,055 per month in 2016," or $12,660 a year, "barely above the poverty line."

Research shows that disability rates are higher in more rural areas, ranging from 11.7 percent in the most urban areas to 17.7 percent in the most rural counties, according to the University of Montana Research and Training Center on Disability in Rural Communities.

The report speculates that rural rates are higher because rural populations are older. The share of people 65 and older in urban areas was 13.6 percent, compared to 18 percent in the most rural counties. The center has county disability data at http://rtc.ruralinstitute.umt.edu/resources/disability-counts-data-finder/.