Lawmakers passed several health-related bills in last two days of session, but killed others, including one to help with insulin costs

By Melissa Patrick
Kentucky Health News

The General Assembly passed several health-related bills in the final days of its session, but left many others hanging, including an insulin bill aimed at helping Kentuckians with diabetes pay for their life-saving medication.

Rep. Danny Bentley

House Bill 12, sponsored by Rep. Danny Bentley, R-Russell, would have required state-regulated insurance plans to cap a patient's cost for a 30-day supply of insulin at $100 "regardless of the amount or type of insulin needed to meet the covered person's insulin needs." It did not include Medicaid, Medicare or self-insured government plans.

The Senate committee substitute for HB 12 would also have established an insulin assistance program. This language came March 18 from Senate Bill 23, sponsored by Sen. Phillip Wheeler, R-Pikeville. After sitting in the Rules Committee for several legislative days, it was recommitted on the last day -- without explanation, as usual.

“I hate to use the word disappointing; it's worse than that, really,” Bentley said. “I apologized to all of my representatives because I had 73 co-sponsors on that bill. And that is disheartening to me, not because of me or anything for me, but because of the 550,000 diabetics in Kentucky. And right now with people not able to work, it just made it that more important.”

Sen. Phillip Wheeler

He said he thought Wheeler's addition “killed it,” largely because of the added cost that came with his assistance program, and trying to figure out who would pay for it. (He added it at a time when the covid-19 pandemic was becoming a threat to state revenues.) "It just got too complicated,” he said. “HB 12 should have come on through clean.”

Bentley said if the Senate had passed the bill with Wheeler's addition, he was planning on asking the House to reject the changes and sending the bill to a conference committee that he thought would have removed Wheeler's program.

Wheeler acknowledged that the funding for his program was an issue, but said the main reason the bill didn't pass was the shortened legislative session.

"I think it just got caught up in the whirlwind of covid-19," he said. "It just didn't make the cut." He said he was also disappointed. "I think it was a great bill that would have helped a lot of people, but like I said -- I guess we'll just have to try again next year." Bentley said his bill will be a priority when the legislature returns in January.

Wheeler said the addition of his amendment was important because Bentley's bill covered fewer than 10 percent of health plans in Kentucky and his amendment would have also helped the uninsured and those who are covered by most private-sector health plans, called ERISA plans.

“To the extent that it caused any problems for his bill, I do regret that. But honestly, I don't know that Bentley's bill really had any better chance of passing than mine did.”

Wheeler was serving his first full legislative session after winning a special election in March 2019. He is running for a full four-year term and will have a Democratic opponent after the June 23 primary. His district is Pike, Martin, Lawrence and Morgan counties.

Bentley, a pharmacist who was first elected in 2016, is unopposed for another two-year term from Greenup County and part of Boyd County.

Another major health bill that did not pass was aimed at improving the workforce that cares for patients with Alzheimer's disease and dementia.

SB 136, sponsored by Sen. Robby Mills, R-Henderson, would have required home-health aides who provide care for patients with Alzheimer's or other dementias to receive four hours of state-approved dementia-care training within the first 60 days of employment, and two hours per year after that. A committee heard that of the 75 hours it takes to become a certified nurse's aide, only two focus on cognitive impairment.

The bill was amended with a business-oriented coronavirus relief measure in the last hours of the session, and the revised version passed out the House 86-3. The Senate did not agree to the changes; a Senate spokesman told the Lexington Herald-Leader that there were issues with the bill that the legislature did not have time to correct.

The health-related measures in the amendment would have allowed chiropractors to go back to work, and allowed certified community-health workers to bill Medicaid for their services during the state of emergency. It also included language that asked occupational licensing boards and trade associations to give Beshear a plan showing how they could safely reopen while still following health guidelines.

Another transformed measure that didn't pass was Senate Bill 20, which was completely gutted in the House and amended to allow massage-therapy and optician boards to set their licensing fees in administrative regulations, rather than law, and designate a single credential-verification agency for all the state's Medicaid managed-care organizations. Health-care providers have long complained about the burden of being separately credentialed by MCOs; the state has five.

Rep. Kim Moser, R-Taylor Mill, said the bill would have set a firm deadline, July 1, for the Cabinet for Health and Family Services to create a credentialing agency, and if not, responsibility would shift to the attorney general. The General Assembly passed legislation in 2018 to create such a system, but it hasn't been implemented, she said.

Another bill related to MCOs that did not pass was SB 30, sponsored by Sen. Stephen Meredith, R-Leitchfield. It would have limited the number of MCOs to three. Meredith and others say there is no need for providers to have to deal with the administrative burdens of dealing with so many MCOs; opponents say that makes bidding more competitive.

Health bills that passed

Health bills that did pass include measures to promote organ donation, help struggling rural hospitals and Sudden Infant Death Syndrome research, boost reimbursements for ambulance services, and make it harder to get an abortion, among other things. All of these bills await action by Beshear, whose decision will be final because April 15 was the last day the legislature could meet.

Here are most of the health-related bills that passed in the final two days of the legislative session:

HB 387, sponsored by Bentley, would create a revolving loan fund for financially distressed rural hospitals. It is not funded but would allow the Cabinet for Economic Development to provide loans to struggling hospitals to maintain or upgrade their facilities; to maintain or increase staff; or to provide new health-care services. It passed with an amendment to give Beshear the authority he needs to buy protective gear for health-care workers fighting the covid-19 pandemic.

HB 46, sponsored by Rep. Jerry Miller, R-Louisville, would allow full-time state employees a paid leave of absence of 240 hours for donating a human organ and 40 hours for donating bone marrow.

SB 237, sponsored by Sen. Max Wise, R-Campbellsville, would allow collection of tissue samples from post-mortem exams of children who have died from Sudden Infant Death Syndrome to be used for research purposes, with a parent's permission.

SB 9, sponsored by Sen. Whitney Westerfield, R-Hopkinsville, would require health-care providers to give "medically appropriate and reasonable life-saving and life-sustaining medical care and treatment" to any infant born alive, including after a failed abortion, and would make not doing so a felony. The bill passed with language from HB 451, to expand the power of the attorney general to shut down abortion providers and keep abortion from being deemed an urgent procedure under Beshear's emergency order. Westerfield said he expects Beshear to veto the bill.

HB 8, sponsored by Rep. Rob Rothenburger, R-Shelbyville, would boost reimbursement from Medicaid for ambulance services by setting up a trust fund to let them draw a federal match.

HB 29, sponsored by Rep. Steve Riley, R-Glasgow, would make temporary licenses for long-term-care administrators run nine months, not six.

House Resolution 135, sponsored by Rep. Kim Moser, R-Taylor Mill, would encourage the Legislative Research Commission to establish the Kentucky Emergency Preparedness Task Force, with findings to be submitted by Dec. 1. Moser said it should look at the state's past and current response to disasters, including covid-19, and plan for future response.

Click here for a list of some other health-related bills that have already been signed by the governor.

4 new test sites announced; legislature drops business bill that raised Beshear's ire; state Chamber sets 'what next' webinars

An intubation box, similar to one shown by Dr. Steven Stack at the governor's daily briefing, is used
to limit health-care workers' exposure to the coronavirus when intubating a patient. (WDRB image)  

As news develops in Kentucky about the coronavirus and its covid-19 disease, this item will be updated. Official state guidance is at https://kycovid19.ky.gov.

Gov. Andy Beshear announced four more sites to test Kentuckians for the coronavirus, and deferred most comment on President Trump's plan for relaxing restrictions to fight it, at his daily briefing Thursday.

Beshear said the Kroger-sponsored sites will be open in Paducah, Madisonville, Somerset and Pikeville Tuesday through Thursday, with a goal of testing 1,000 people apiece. He said they will be open to people in the respective regions, not just the counties of the testing sites or adjoining counties, the practice for the first two sites, in Franklin and Kenton counties. The Kenton location is open through Saturday. To schedule a test at one of the Kroger sites, go to thelittleclinic.com/drive-thru-testing. "Let's not leave one test unused," he said.

Beshear said he had seen a "high-level summary" of Trump's plan, and heard it discussed on a call for governors, but would reserve specific comments on it until Friday because "I think he ought to be able to present it."

"It is just a recommendation that states take certain steps," he said. "A lot of them are the guidelines that we’re thinking about and would have been talking about tomorrow," when he had already planned to discuss the topic.

He said that on Friday, he will give his analysis of the plan and “our additional metrics . . . and maybe where we are on some of those metrics. . . . It's gonna take significant amounts of testing and then contact tracing.” The plan included no guidance for states on those points.

Beshear reiterated that easing of restrictions will be gradual, and differential. “The new normal is going to be different than our old normal,” he said, adding, “Our seniors and vulnerable populations are still gonna be very very much at risk from this virus.”

Also, he said, “We believe we are still on an upward trajectory” in cases and deaths. He announced 159 new cases, for a corrected total of 2,429, and said “We believe tomorrow is gonna be one of the highest numbers we’ve seen because many reports have been delayed. “What we really need to look at are the averages over these days,” he said.

One of the new cases was a 10-day-old baby in Lincoln County. “This is a family that just had a miracle occur and is probably living through a nightmare,” Beshear said.

In other covid-19 news Thursday:

• Showing a social-media comment that nothing can be done about people dying from covid-19, Beshear said, "There is something that everybody can do about this coronavirus. It's following those 10 steps. If you stay healthy at home, then you prevent people from dying. If you engage in social distancing, then you can stop people from dying. If you make sure that you follow our 10 rules . . . that is how we do everything it takes to beat this virus. It is in each and everyone of our hands."  
• Beshear announced that seven more Kentuckians had died from covid-19, bringing the state's total to 129. The most recent deaths were a 79 year-old man and 68- and 92-year old women from Jefferson County; an 85-year-old man from Jackson County; a 78-year-old woman from Adair County; a 69-year-old woman from Shelby County; and a 67-year-old female from Graves County. 
• The General Assembly did not pass a last-day bill that would have directed trade groups and licensing boards to give Beshear a plan for safely reopening certain businesses. Senate Bill 136 passed the House 86-3, but got no action in the Senate. WLKY-TV reports, "A spokesperson for Senate Republicans said the bill had technical flaws, and there was not time to get it redrafted." Beshear, who had objected to the idea, could have vetoed the bill without fear of a legislative override.
• The legislature overrode a vetoed section of the budget bill prohibiting Beshear from spending unbudgeted funds without legislative approval, but added language to a rural-hospital bill allowing unbudgeted restricted funds to be used for personal protective equipment during the state of emergency.  
• The governor said Western State Hospital in Hopkinsville saw five new cases and Green River Correctional Complex in Central City saw two new cases, one inmate and one staffer.  
• The state's long-term care facilities had 27 new cases and one new death. Eleven of the new cases were among staff. In all, 283 residents and 148 staff have tested positive for the virus , and 37 residents and one staffer have died.  
• Kentucky, Wisconsin, Illinois, Minnesota, Michigan, Indiana and Ohio have joined to closely coordinate plans to repoen their economies, Beshear said. Asked what would be needed to partner with Tennessee, he said Tennessee had taken a different approach and had not reached out to Kentucky, "and I guess given some of my comments I can understand that." When Tennessee had relatively lax rules and a higher rate of cases, Beshear compared the two states' performances.
• Health Commissioner Steven Stack showed a plexiglass intubation box made by First Build, a subsidiary of General Electric, to place around heads of covid-19 patients to help protect health-care workers from exposure to the virus when they place breathing tubes in the patients. He said First Build has made 500 boxes to be distributed across the state.
• Beshear said the state will offer non-congregate shelter for persons needing isolation at Lake Barkley and Lake Cumberland state resort parks, beginning Sunday, April 19. Placement will be by referral only from public health and clinicians, for people who are sick or have been exposed to the virus and cannot safely go home and have nowhere else to go. They will get meals, basic first aid, TV and internet access. He said other parks will be used as needed. The program will help relieve pressure on hospitals as well as to prevent the spread of the virus, he said.
• The Lexington Herald-Leader reports on how Kentuckians who have lost health insurance because of covid-19 can apply for Medicaid.
• The Kentucky Chamber of Commerce is hosting two webinars in response to the covid-19 pandemic. The first, "How Can Business Re-Open and Protect Public Health?" will be at 1 p.m. Tuesday, April 21. Click here to register. The second, "How Does Kentucky's Economy Rebound From Covid-19?" will be at 2 p.m. Thursday, April 23. Click here to register.
• UK Now tells the story of how staff and volunteers with the Cooperative Extension Service are assembling face shields and sewing masks for the state's health-care industry. 
• Stat, in collaboration with the Center on Rural Innovation and Applied XL, created an interactive dashboard that examines every U.S. county's covid-19 preparedness level. 
• With a 30 percent false-negative rate, largely because of difficulty getting a proper sample, many are concerned that using some current covid-19 tests to see who can go back to work is not reliable. Stat reports that China has used a chest CT scans to diagnose infections, which one study found to be 97% reliable.  
• The Associated Press reports that the federal government is under pressure to publicly track nursing-home outbreaks and deaths. "This is basic public health — you track this, you study it, and you learn from it," said David Grabowski, who specializes in health-care policy at Harvard Medical School. He told the AP that it's difficult to have confidence in officials' ability to contain the virus if they aren't tracking where it has struck and why.
• Since April 14, the Centers for Disease Control and Prevention has included probable cases and deaths from covid-19, in addition to confirmed cases and deaths. The Washington Post reports that there is great variance among states in how they tally covid-19 case and death, making it difficult to compare one state to another. Kentucky attributes to covid-19 the death of any person found to have the virus, including in tests after death, which some states don't do.
• "Clinicians around the world are seeing evidence that suggests the virus also may be causing heart inflammation, acute kidney disease, neurological malfunction, blood clots, intestinal damage and liver problems," the Post reports. "That development has complicated the treatment of the most severe cases of covid-19."
• The Post reports, with a graphic, that covid-19 is rapidly becoming America's leading cause of death.

Graphic from The Washington Post shows causes of death in U.S. April 6-12. To enlarge, click on it.

Bill to tax electronic cigarettes at 15% goes to governor; health advocates say it will decrease young people's use of the products

By Melissa Patrick
Kentucky Health News

Kentucky lawmakers gave final approval Wednesday to a tax on electronic cigarettes, which is expected to decrease teen use of the products by increasing their price.

Centers for Disease Control and Prevention illustration; click for larger version 

The Senate added the 15 percent excise tax to the catch-all revenue bill, House Bill 351. It was a trimmed-down version of HB 32, which, among other things, would have put a 25% tax on e-cigarettes, generating about $50 million.

The reduced tax is expected to generate $25 million, but most of that will be negated by tax breaks for agriculture, coal and alcohol industries, the Lexington Herald-Leader reports.

HB 351 will reduce the taxes to 15% on open "vaping" systems, like those typically sold in "vape" shops, and added a $1.50-per-pod tax on closed vapor cartridges, like those sold by Juul Labs. Gov. Andy Beshear is expected to sign it.

Health advocates expect the tax to decrease teen use of the products. Following is a statement from the Foundation for a Healthy Kentucky, joined by the Kentucky Chamber of Commerce, the Kentucky Cancer Foundation, the Kentucky Equal Justice Center, the Kentucky Health Collaborative, the Kentucky Medical Association, the Northern Kentucky Chamber of Commerce and Kentucky Youth Advocates:

"This new tax is clearly a win for health in Kentucky, especially for our adolescents and teens, because it will result in a significant price increase that will deter many of our youth from using dangerous e-cigarette products," said Ben Chandler, president and CEO of the foundation. "E-cigarettes are the only tobacco product sold in Kentucky currently not subject to an excise tax. The relatively low cost has been a factor -- along with the kid-friendly flavors -- in luring up to 80,000 Kentucky kids to try these highly addictive products.

"We applaud the legislature for adopting a pod tax that will substantially increase the price of the products that are most popular among youth right now, including the Juul and knock-off reusable devices and the Puff Bar and Posh disposable e-cigarettes. In the midst of the coronavirus pandemic, inhaling toxins that are shown to damage the lungs puts these kids and every other smoker and vaper in the Commonwealth at greater risk for serious complications from covid-19. This is an important bill today and for the future, and a strong step in the right direction."

Rep. Jerry Miller, R-Louisville, the sponsor of HB 32, questioned why the Senate didn't include the section of his bill that would have raised the tax on snuff products as a way to generate more revenue. His bill would have doubled the tax on snuff, which includes Snus packets, and he alluded to the lobbying influence of Altria Group, the maker of Snus and the nation's largest tobacco-product manufacturer, with a smokeless-tobacco factory in Hopkinsville.

"Given that Altria had accepted the doubling of ad-valorem tax on snuff and Snus, and was therefore included in the governor's budget and the House budget, I cannot understand why the Senate would not accept that increase in revenue," Miller said in a statement read by House Republican Caucus Chair Suzanne Miles as most members voted and communicated remotely due to the threat of the coronavirus. But some thought the bill was still too much.

Sen. Robin Webb, D-Grayson, said she voted against it because she had not had time to read and digest it, and because she had filed several amendments, including one for a 10% tax. Sen. Tom Buford, R-Nicholasville, who also favored that rate and voted no, said "I am fearful that the vaping tax at 15 percent will drive many of our individuals trying to free themselves from the tobacco products back to them, not only that, but our youthful individuals."

Others voting no in the Senate were C.B. Embry of Morgantown, Jimmy Higdon of Lebanon, Albert Robinson of London, John Schickel of Union, Brandon Smith of Hazard and Whitney Westerfield of Hopkinsville, all Republicans. Five senators passed and five did not vote, for a roll call of 20-8-5. The House passed the bill 68-22.

Here are some resources to help quit smoking:

• Quit Now Kentucky offers nicotine replacement therapy and counseling , call 1-800-QUIT-NOW (800-784-8669) or text QUITKY to 797979.
• My Life, My Quit, a quit-vaping service for teens that provides coaching by text message, by phone, or by online chat; call 855-891-9989 or text START MY QUIT to 855-891-9989.
• This is Quitting, a free coaching service for those ages 13-24 to help them quit using e-cigarettes; text KENTUCKY to 88709.

Lawmakers returning to Frankfort to pass a budget and other bills; here are some health-related measures that could pass

UPDATE: On April 1 the General Assembly passed a state budget and related bills, including one freezing health departments' pension payments at the current level. House Speaker David Osborne said more bills are likely to pass when the legislature returns April 13, including one to help rural hospitals..

By Melissa Patrick
Kentucky Health News

As lawmakers head back to Frankfort to pass a budget -- and other bills, despite Gov. Andy Beshear's repeated request that they pass only a budget and anything related to the coronavirus -- several big bills related to other aspects of health are pending, including some controversial measures.

Beshear, a Democrat, denied the request of the Republican legislative majority to call a special session after the threat abates, if they adjourned early. He said it might not be safe to call them back in time to pass a budget, which must be done by June 30. The lawmakers plan to pass the budget and other bills Wednesday, April 1, and return April 14 to reconsider vetoed bills.

Beshear indicated at his daily press conference Tuesday that the budget would be the only bill passed. “These folks need to pass a budget and get of town,” he said. “My understanding is that now, that’s the plan.”

One big health-related bill that has been expected to pass is House Bill 32, which would tax electronic cigarettes. It has been promoted as a way to reduce teen use of the products by increasing their price and to bring state government more money -- an increased concern in light of the pandemic, which is likely to cause a recession and a drop in state revenue.

HB 32 was trimmed down in a Senate committee to place a 15 percent wholesale tax on e-cig products and a $1.50 per-pod tax on Juul-type products, which is expected to bring in $25 million a year. The original bill was estimated to bring in $50 million, and that could be trimmed down even further, as two Senate floor amendments have been filed to decrease the tax to 10%.

The original version would have put a 25% tax on e-cig products, while raising the tax for "other tobacco products," such as cigars, to 25% from the current 15%, and add e-cigs to the list. It would have also doubled the per-unit tax on non-smokable products, but did not touch the tax on traditional cigarettes.

Health departments: Another health-related bill to watch is one that has been touted in the House as part of a three-phase approach to create a sustainable solution to local health departments' pension-driven financial woes.

House Bill 171, sponsored by Rep. Jim DuPlessis, R-Elizabethtown, would move health departments, regional universities and quasi-governmental agencies away from a "percentage of pay" pension formula to a model that requires them to pay only what they owe the system over a certain period, called "level-dollar funding." It is in the Senate State and Local Government Committee but has had two official readings, so it could pass quickly.

It could pass another way: in a House committee substitute to SB 249, with a change to include a new 30-year-amortization period for the pension debt, rather than the 27 years in HB 171. It also adds a layered, 20-year closed amortization period for any future increases or decreases in actuarially accrued liabilities after the 2019 valuation. SB 249 has received two readings in the House, and DuPlessis has said negotiations will likely be done through SB 249.

Rural hospitals: HB 387, sponsored by Rep. Danny Bentley, R-Russell, would create a revolving loan fund for financially distressed rural hospitals.

It would allow the Cabinet for Economic Development to provide loans to struggling hospitals for three purposes: to maintain or upgrade their facilities; to maintain or increase staff; or to provide health-care services not currently available. The bill has had two readings and is in the Senate Appropriations and Revenue Committee.

Insulin costs: Another important health-related bill would cap the monthly cost of insulin for many Kentuckians at $100. HB 12, sponsored by Bentley, would require state-regulated insurance plans to cap a patient's cost for a 30-day supply of each insulin prescription at $100 "regardless of the amount or type of insulin needed to meet the covered person's insulin needs." It does not include Medicaid, Medicare or self-insured government plans.

The Senate committee substitute for HB 12 would also establish an insulin assistance program. This language comes from SB 23, sponsored by Sen. Phillip Wheeler, R-Pikeville. HB 12 has had two readings and is in the Senate Rules Committee.

Abortion: At least one anti-abortion bill is likely to move; it has been awaiting final passage for some time. Senate Bill 9, sponsored by Sen. Whitney Westerfield, R-Hopkinsville, would require health-care providers to give "medically appropriate and reasonable life-saving and life-sustaining medical care and treatment" to any infant born alive, including after a failed abortion, and would make not doing so a felony. A House committee removed references to research, so it would not inhibit ongoing research.

Critics of the bill say the state already has laws to prevent this from happening and the bill does not account for palliative care needed when infants will not live, or will not have quality of life.

Another abortion bill that could pass is House Bill 451, sponsored by Rep. Stan Lee, R-Lexington, which would expand the power of the attorney general to shut down abortion providers. The Senate Judiciary Committee added authority for Attorney General Daniel Cameron to block abortions under gubernatorial emergency orders limiting "non-urgent" medical procedures.

Sen. Ralph Alvarado, R-Winchester, has filed a floor amendment to ban abortion from being deemed an urgent procedure in the state of emergency Beshear declared for covid-19. Democratic Floor Leader Morgan McGarvey of Louisville has filed an amendment to allow abortions in the case of a nonviable fetus, rape, incest, or threat to the mother's life.

HB 451 has had only one reading in the Senate, so it could not pass Wednesday unless the Senate suspended the readings requirement, which the state constitution allows it to do. Majority Floor Leader Damon Thayer said last week that was a possibility, but he voiced skepticism of the idea because it might set a precedent that legislative leaders would like to avoid. The legislature could pass it April 14 or even April 15, the day the session must end, but Beshear could veto it without fear of a legislative override.

Another abortion bill pending is House Bill 67, sponsored by Rep. Joseph Fischer, R-Fort Thomas, which would, in effect, ban abortion in Kentucky if Roe v. Wade is overturned. It would have the constitution say, "To protect human life, nothing in this Constitution shall be construed to secure or protect a right to abortion or require the funding of abortion." The bill has had no readings in the Senate, but is a constitutional amendment that would go directly to the Nov. 3 ballot, not to Beshear, so it could pass if the legislature met April 15 or if it suspended the readings requirement.

Here are some other health-related bills that could pass:

HB 29, sponsored by Rep. Steve Riley, R-Glasgow, would extend temporary license for long-term care administrators to nine months, not six. It awaits House concurrence with a Senate substitute that would prohibit certification or renewal of an assisted-living community if it is owned, manged or operated by a person who has been convicted of certain crimes it would also change the appeals and renewal processes.

HB 46, sponsored by Rep. Jerry Miller, R-Louisville, would allow full-time state employees a paid leave of absence of 240 hours for donating a human organ and 40 hours for donating bone marrow. This bill is on the Senate consent calendar, which is used to pass bills en masse without debate.

HB 8, sponsored by Rep. Rob Rothenburger, R-Shelbyville, would boost Medicaid reimbursements for ambulance services by setting up a trust fund to allow them to draw a federal match. This bill is on the Senate consent calendar.

SB 30, sponsored by Sen. Stephen Meredith, R-Leitchfield, would  limit the number of managed-care organizations to three, from the current five. This bill has received a reading in the House and been returned to the Health and Family Services Committee.

SB 237, sponsored by Sen. Max Wise, R-Campbellsville, would  allow collection of tissue samples from post-mortem exams of children who have died from Sudden Infant Death Syndrome to be used for research purposes, with a parent's permission. This bill is also in the House Health and Family Services Committee, with one reading.

A more comprehensive list of health bills in the General Assembly, compiled by Kentucky Health News in a Google Doc, is available here.

Beshear signs more than 35 bills amid pandemic, many related to health care; physician assistants get limited prescribing power

By Melissa Patrick
Kentucky Health News

The Kentucky legislature continues to pass bills despite Gov. Andy Beshear's plea that it just pass a budget and anything related to the coronavirus, due to the social distancing needed to thwart it. He announced Saturday that he had signed more than 35 bills into law, many of them related to health.

“While all of us should be focused on responding to the coronavirus as the number of cases grows in Kentucky, I will continue to evaluate the dozens of bills lawmakers are passing and sign those I believe will benefit the people of the commonwealth,” he said in a news release. “While all of these issues could be addressed after we defeat the coronavirus, my staff and I will continue to look out for the best interests of all Kentuckians in deciding which bills should become law.”

Beshear, a Democrat, earlier rebuffed the request of Republican legislative leaders to call a special session after the threat abates, if they adjourned early. He said it might not be safe to call them back in time to pass a budget, which must be done by June 30. They plan to pass the budget and other bills April 1, and return April 14 to reconsider vetoed bills; he has vetoed two.

Here are some of the health-related bills Beshear signed:

Senate Bill 50, sponsored by Sen. Max Wise, R-Campbellsville, requires the state to hire a single pharmacy benefit manager to manage Kentucky Medicaid's $1.7 billion-a-year prescription drug business. This bill is designed to address many of the billing practices between pharmacy benefit managers and pharmacists, which pharmacists have long said are so unfair that they are putting some of them out of business.

House Bill 135, sponsored by Rep. Steve Sheldon, R-Bowling Green, gives physician assistants "modified prescriptive authority" for controlled substances in Schedules III, IV and V after they've practiced a year. Sheldon said all other states allow prescriptive authority for PAs and Kentucky will become the sixth state to place restrictions on them for Schedule II drugs, which includes a long list of narcotics used for pain management as well as several psycho-stimulants that are used treat attention deficit hyperactivity disorder, or ADHD.

SB 56, sponsored by Sen. Ralph Alvarado, R-Winchester, brings Kentucky law in line with the new federal law raising the legal age to purchase tobacco products, including electronic cigarettes, from 18 to 21. It also removes status offenses for youth who "purchase, use or possess" tobacco products, which are often called PUP laws. The bill allows the products to be confiscated and shifts the penalty to retailers who fail to adequately check buyers' identifications. The bill had an emergency clause so it became law upon Beshear's signature.

SB 42, sponsored by Sen. Denise Harper Angel, D-Louisville, requires any student identification badge issued to a public middle- or high-school student to contain the contact information for national crisis hotlines specializing in domestic violence, sexual assault and suicide. This contact information must also be on all IDs issued by public or private postsecondary education establishments. This information must be included on the IDs beginning Aug. 1.

SB 60, sponsored by Sen. Jimmy Higdon, R-Lebanon, adds spinal muscular atrophy, also referred to as SMA, to the list of  required tests run on infants for heritable disorders. Early diagnosis of this genetic disease helps babies receive treatment when it is most effective. Including SMA, Kentucky will now do 60 newborn screenings. Alvarado said at the bill's Jan. 29 committee hearing that this condition affects five or six Kentucky babies each year. 

SB 82, sponsored by Sen. Julie Raque Adams, R-Louisville, establishes the Kentucky Eating Disorder Council to oversee development and implementation of eating-disorder awareness, education and prevention programs. It will also identify strategies for improving access to adequate diagnosis and treatment services. and make recommendations on legislative and regulatory changes. Adams said 900,000 Kentuckians, including nearly 30,000 children, have been diagnosed with an eating disorder but the state has no residential, partial-hospitalization or acute-care programs.

SB 134, sponsored by Sen. David Givens, R-Greensburg, establishes the Optometry Scholarship Program with a trust fund supplied by state appropriations (determined with each biennial budget) gifts, grants, and federal funds. A minimum of one-third of the amount appropriated for scholarships must go to eligible students at an in-state institution -- a boon to the University of Pikeville's Kentucky College of Optometry, the state's only optometry school.

SB 125, sponsored by Sen. Tom Buford, R-Nicholasville, allows the Kentucky Board of Medical Licensure to determine the allowable scope of practice for athletic trainers in Kentucky, particularly related to their training. This bill has been in the works for about 10 years.

HB 153, sponsored by Rep. Kim Moser, R-Taylor-Mill, establishes a mental-health first-aid training program to show people how to best meet the needs of someone in a mental-health or substance-use crisis. Funding will come through a trust supplied by state and federal appropriations, grants and private donations. Advocates' hope is that this training will become as common as CPR.

Beshear had already signed several other health-related bills into law, including:

HB 129, sponsored by Moser, will overhaul the state public-health system, including how health departments are funded and how they prioritize their resources.  It is called the public health transformation bill. It was fully funded in the House budget but falls about $9.4 million short in the Senate's proposal, according to Randy Gooch, director of the Jessamine County Public Health Department. HB 129 is part of a three-phase approach submitted in the state House to create a sustainable solution to local health departments' pension-driven financial crisis.

SB 122, sponsored by Adams, modifies Tim's Law of 2017, which allows judges to order assisted outpatient treatment for people who have been involuntarily hospitalized at least twice in the previous year. SB 122 would make that two years. The goal of Tim's Law is to stop the revolving door of these individuals in and out of jails and state psychiatric hospitals, allowing more participants. The law is named for Tim Morton of Lexington, who was hospitalized involuntarily 37 times by his mother because it was the only way she could get him the psychatric treatment he needed. He died in 2014.

HB 99, sponsored by House Speaker David Osborne, R-Prospect, authorizing a $35 million state loan to the University of Louisville to support its recent acquisition of Jewish Hospital and other Louisville health-care facilities.

House Concurrent Resolution 5, sponsored by Rep. Danny Bentley, R-Russell, asks the federal government to expedite research on the safety and efficacy of medical marijuana. A House-passed bill to make marijuana legal medicine in Kentucky has gotten nowhere in the Senate. 

Legislature passes bill to support state response to covid-19; includes many suspensions and changes in health-care rules

Rep. Patti Minter, D-Bowling Green, wears a mask as she uses her phone on the House floor during a recess. At right is Rep. Chris Fugate, R-Chavies. (Kentucky Health News photos by Melissa Patrick)

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill supporting and enhancing Gov. Andy Beshear's executive orders to address the coronavirus pandemic passed without dissent in both chambers of the legislature Thursday, with a caution that more measures will likely be needed.

"Things evolve as we know day to day on this issue, and I'm sure there will be more needs," Sen. Ralph Alvarado, R-Winchester, said in describing the bill. Senate President Robert Stivers told Kentucky Health News that this is likely the first step of many to address this issue, and Senate Democratic Leader Morgan McGarvey of Louisville, said,  "This a good bill and it's a good start."

Senate Bill 150, generally called the "Covid-19 relief bill," was gutted of its original language about surprise medical billing and amended to offer relief on several fronts for covid-19 response.

The bill has several health-care provisions, including one to make it easier for providers to serve patients through telehealth, including one to allow out-of-state providers to practice telehealth in Kentucky.

It also clarifies language on what is considered emergent or urgent care, stating that a health-care procedure can be performed it it meets this criteria. It also allows services like physical therapy, occupational therapy, or alcohol- and drug-abuse treatment to be administered if they are ordered by a physician licensed in Kentucky.

Those provisions are in response to Beshear's order for medical facilities and providers to cease all elective procedures as a way to keep hospital beds available and preserve personal protective equipment.

The bill also has provisions aimed at expanding the state's health-care workforce.

For example, it allows the state Board of Medical Licensure, the Board of Emergency Medical Services and the Board of Nursing to waive or modify licensure or certification requirements for health-care providers who are licensed or certified in other states to provide those services in Kentucky.

It also relaxes the scope of practice requirements to allow health-care providers to practice in all settings of care; allows physicians to supervise a larger number of other providers and to do it by telephone; allows rapid certification, licensing, re-certification or re-licensing of providers; allows medical students to care for patients under a provider's supervision; and allows reactivation of licenses for inactive and retired health-care providers so that they may render service.

The bill also provides immunity for health-care providers who render care in good faith to covid-19 patients during the state of emergency, as well as immunity for Kentucky businesses acting in good faith to make or provide personal protective equipment or personal-hygiene supplies related to covid-19, and that don't make or provide such products.

A time of crisis

The bill passed on a day that Kentucky reported 50 new cases of covid-19, its largest one-day increase so far, for a total of 248. It also came at a time that Beshear warns the public daily that the next few weeks are expected to get worse.

“The next two to possibly three weeks is gonna be absolutely critical in our battle against the coronavirus,” Beshear said at his daily press conference March 25, repeating the point several times.

Rep. Terri Branham Clark, D-Catlettsburg, also wore a mask.

The bill also has provisions to help those who have lost their jobs or have had their hours decreased because of covid-19. It waives the seven-day waiting period for unemployment benefits, extends benefits to those who are self-employed, and allows those who were not let go, but simply had their hours cut back, to also apply.

"The number of workers who filed for unemployment jumped to 48,847 from 2,785 the week before, according to non-seasonally adjusted figures from the Labor Department," Alfred Miller reported March 26 for the Louisville Courier Journal.

Among other provisions, the bill also extends the state deadline for filing income taxes to be the same as the new federal deadline, July 15, and removes all penalties and interest that could result from such extensions; permits restaurants with a license to sell alcoholic beverages in conjunction with takeout food orders; authorizes funds to support the state's covid-19 hotline; and extends the length of time government entities have to respond to an open-records request to 10 days, from three.

The bill also:

• Allows the governor to direct the suspension or waiving of the collection of licensing fees, renewal fees, application fees, and other administrative requirements where they are required by the state. Licensees may continue working without interruptions, and shall be granted at least 30 days after the expiration of the state of emergency to pay any fees or complete any administrative obligation before any action is taken.
• Allows a public agency to delay on-site inspections during the emergency. Public agencies may conduct their meetings by live audio or live video teleconference, with information on how the public and media can access the meeting.
• Suspends deadlines related to land use, planning and zoning, and deadlines for code enforcement proceedings and hearings.
• Allows taxing districts to suspend or otherwise extend applicable deadlines.
• Suspends the rule that a notary certify a signature after face to contact, if they can communicate via a video teleconference in real time.
• Requires Beshear to declare when the state of emergency has ceased, and if he has not done so by the first day of the next regular legislative session, the General Assembly may make that determination.

The report from the House-Senate conference committee that wrote the bill points out that its actions "are not statements of approval or disapproval relative to any executive order or action," but are necessary to support Beshear's actions during the state of emergency because the General Assembly is  responsible for creating or modifying law and for creating policy.

Asked as the bill was nearing passage what he needed from it, Beshear said, "I need maximum flexibility. We are living this battle and we are fighting it day by day. I need the maximum amount of financial flexibility. I need the maximum amount of flexibility if we have to take more restrictive steps. We need the flexibility to be able to move very fast to work with local governments … and local law enforcement when needed."

The bill has an emergency clause, which means it will become law as soon as Beshear signs it.

Bill to tax e-cigarettes whittled down; heavy tax on Juul-like pods remains; teens warned of health dangers of vaping and covid-19

The bill aims to reduce youth use of e-cigarettes. (Getty Images)

By Melissa Patrick
Kentucky Health News

A House bill aimed at reducing teen use of electronic cigarettes by increasing their price, while bringing the state more revenue, was trimmed down to its bare bones in the Senate and is now expected to generate $25 million, not $50 million.

"The amended bill only covers vaping and Juul-type products," said Sen. Chris McDaniel, chair of the Senate Appropriations and Revenue Committee. "The floor [stock] tax is eliminated as part of this. It is a 15% wholesale and $1.50 per-pod tax and that is the entirety of the bill."

Later, McDaniel said he had realized that the floor-stock tax on existing inventory had not been deleted from the amended version of the bill and said he would file a Senate floor amendment to get rid of it. The new version of House  Bill 32 is expected to generate an estimated $9 million in 2021 and $16 million in 2022.

The House version of the bill would have put a 25 percent wholesale tax on e-cigarette products, while raising the wholesale tax for "other tobacco products," such as cigars, to 25% from the current 15%, and add e-cigs to the list. It would have also doubled the per-unit tax on chewable and non-smokable products, but did not mention the tax on traditional cigarettes.

The bill, sponsored by Rep. Jerry Miller, R-Louisville, has been a priority for the Foundation for a Healthy Kentucky. President and CEO Ben Chandler told Kentucky Health News that while the foundation wanted the House version, it still considered it a win because of the pod tax.

"We think by and large this is good news," Chandler said. "We believe that the tax on pods, which is about $1.50 per pod, would put a significant dent in the youth use of cartridge-based e-cigarettes, like Juul. . . . All data shows that if the price goes up, youth use goes down, and we're interested in seeing a decline in youth use."  

According to the 2019 Youth Risk Behavior Survey, nearly 54% of Kentucky high-school students and 31% of middle-school students said they had tried an electronic "vaping" product and 26% of the high schoolers and 17% of the middle schoolers said they had used them during the 30 days before the survey.

Chandler stressed that it is especially important right now to get the word out to teens to stop using these products because they are known to damage the lungs, particularly while the coronavirus is going around.

"The coronavirus is a disease that attacks the lungs and if the lungs are damaged, it makes a person much more vulnerable," he said.

Miller also sounded a warning about smoking while this virus is going around. "The preliminary research does say that smokers as well as vapers are a little more susceptible to covid-19 because it is a respiratory disease," he said.

Chris Mooney of The Washington Post reports, "Experts note that damage to the lungs from pollutants that result from combustion -- whether inhaled deliberately by smokers, or inadvertently by those in regions with poor air quality -- may increase the risk of respiratory tract infections from viruses such as the novel coronavirus. Poor air can also cause lung inflammation that could worsen the symptoms of covid-19."

Industry was willing to accept a lower tax, might still get it

Tony Florence and Adam Seizemore of the Kentucky Smoke Free Association, an organization that represents about 300 "vape" shops in Kentucky, spoke against the bill.

Asked if the association could support the 15% tax,  Florence said, "That is still a fairly substantial burden. . . . For us, 10% was the magic number and we had discussed that with several senators, so I'm not comfortable saying whether 15% would be acceptable or not, but it is a far cry better than 25."

Some senators expressed interest in lowering the tax when the bill gets to the full Senate.

Florence said he was pleased that the new version of the bill did not include the floor-stock tax or an additional hardware tax, which McDaniel said would only be subject to the 6% sales tax.

"You all have done most of the work for me," Florence told McDaniel. "That's great."

Chandler said removal of the floor-stock tax was a mystery. He said it would have kept retailers from piling up inventory at the lower tax rate. "We're sorry that that was removed," he said.

"Vape" shops generally don't sell closed systems that use pods, like Juul, which are most popular with youth, but instead sell open-tank systems that "vapers" fill with e-liquids.

Florence cited a National Bureau of Economic Research study that found  for each 10% shift in e-cigarette price, there was a corresponding 26% reduction in e-cigarette sales and an 11% increase in combustible cigarette sales.  He also cautioned that excessive taxes on e-cigarettes would create a black market for the products. "Vape taxes drive people back to smoking," he said.

He called e-cigarettes  a "harm reduction product" and said they were "95% safer than traditional combustible cigarettes." He said it was the industry's goal to transition people off of combustible cigarettes to "a much less harmful product."

Florence referred to a British study that was debunked in a recent American Journal of Public Health article, which included an appendix of research to back up its conclusions. It said, "The evidence-lacking estimate derived in 2013 cannot be valid today and should not be relied upon further."

And a 700-page U.S. Department of Health and Human Services report says more research is needed before it can be concluded that e-cigs help people stop smoking.

The current version of the bill does not tax disposable, flavored e-cigarettes, which have become popular with youth since the FDA imposed a partial flavor ban that did not apply to these products, but Miller said he would make sure they are included in the final version of the bill.

"When we do the conference committee to reconcile the Senate and House versions of HB 32, I will make sure the final language covers disposables and non-disposables in the per cartridge tax," he said in an e-mail.

Chandler said the foundation had been able to see only snippets of the amended bill, taken on someone's cell phone, because the Capitol and Annex are closed to all but members, staff, news media and other designated persons. The committee substitute had not been posted as of 11:30 p.m. Thursday.

Bill to help independent pharmacies goes to the governor

By Melissa Patrick
Kentucky Health News

A bill to resolve payment issues between Kentucky Medicaid's drug middlemen and pharmacists who fill drugs for Kentuckians on the program has finally passed and been delivered to Gov. Andy Beshear.

Pharmacy benefit managers deal between insurance companies and drug manufacturers; they determine what drugs are offered, how much someone pays for the drug, and how much the pharmacists are paid.

Each of the state's five Medicaid manged-care organizations (all but one an insurance-company subsidiary) contract with a PBM. Senate Bill 50 will require the state to hire a single PBM to manage Kentucky Medicaid's $1.7 billion-a-year prescription drug business.

Sen. Max Wise presented SB 50 on Feb. 20 in the
Senate. (Legislative Research Commission photo) 

While going over the House changes to his bill, Sen. Max Wise, R-Campbellsville, said SB 50 is needed to protect community pharmacists, which he praised, pointing out that that they are on the front line of the response to the coronavirus. The Senate concurred with the changes on a vote of 33-1, with Sen. Julie Raque Adams, R-Louisville, voting against it.

Rosemary Smith of the Kentucky Independent Pharmacist Alliance, which says it represents 500 druggists, told Kentucky Health News that she cried tears of joy while watching the bill gain final passage on Kentucky Educational Television, since the Capitol has limited attendance. She said pharmacists from across the state called her in celebration, many of them saying, "We can make it now."

"I really think we've saved community pharmacies across the state with this bill," she said.

Smith told Kentucky Health News in February that said she and her husband were forced to close two of their drug stores because of PBMs' low reimbursement rates. They own Jordan Drug pharmacies in Eastern Kentucky.

She also applauded the collaborative efforts of all of the stakeholders, the Republican lawmakers in  both chambers who championed the bill, the Democratic governor and his appointees in the Cabinet for Health and Family Services.

"Just to see both sides of the aisle, from the governor and the cabinet and the Senate and the House working with independent pharmacies -- it just makes you proud to be a Kentuckian, it really does," Smith said.

SB 50 aims to address many of the billing practices that pharmacists have long said are so unfair that they are putting some of them out of business.

Kentucky lawmakers have been working on these issues for years and hope that the transparency afforded by only having one PBM, along with the new regulations, will finally take care of them.

"It is a shame that we as a legislative body have had to debate this bill," Wise said. "MCOs and the PBMs have had 10 years to fix these problems themselves. The legislature has passed four bills in six sessions trying to rein in the abuse of PBM activity and it feels like a lot of those bills have largely been ignored."

The bill establishes a single preferred drug list, or formulary, to be used by each managed-care firm, instead of each one having its own separate list; and puts the state Department for Medicaid Services in charge of the reimbursement methodologies, including dispensing fees.

It requires the PBM to pay the managed-care firm the actual discounted pharmacy price negotiated with the pharmacy network, or "pass-through pricing;" prohibits spread pricing, in which a PBM keeps the difference between what it bills Medicaid for medications and what it pays the pharmacy to dispense the drug; and prohibits a whole list of fees.

The House amended the bill to include a clear definition of spread pricing to mean "any technique by which a PBM or other administrator of pharmacy benefits charges or claims an amount from an insurer or MCO for pharmacy or pharmacy services, including payment for a prescription drug, that is different than the amount the PBM or other administrator pays to the pharmacy or pharmacist that provided the service."

Smith said, "That's really critical because that's how the money is leaving the state." A state analysis last year called "Opening the Black Box" found that the PBMs made $123 million through spread pricing.

The bill prohibits PBMs from taking any retaliatory actions against pharmacies; prohibits the sole PBM from requiring a Medicaid recipient to use a mail-order pharmacy; and creates a committee to make recommendations to the state about reimbursement methodologies and dispensing fees.

It's not universally popular

In one of the biggest changes, the measure will prohibit the PBM from requiring Medicaid recipients to get specialty drugs from a pharmacy that is owned or operated by the PBM.

After the bill passed the House March 12, CVS Health, the drugstore chain that holds most of the state's current PBM business through its CVS Caremark subsidiary, said the bill would cost Kentucky $382 million each year without improving the health outcomes for people on Medicaid.

CVS told Kentucky Health News that its analysis, based on what has happened in other states that moved to a single preferred drug list, shows Kentucky can expect to see an 8 percent drop in its rate of dispensing generic drugs, which it said would cost the state $250 million.

It also said that if the state moves to the same dispensing rate as is currently used in fee-for-service Medicaid, which is the average cost of the drug plus a $10.64 dispensing fee, the state will see a $132 million increase in the fees.

Don Kupper, president of the Kentucky Pharmacists Association, disputed the CVS assertions, saying in an email that it is not uncommon for states switching to a single formulary to see a small drop in generic dispensing, but that isn't likely to affect overall costs. "The gross impact figure provided by CVS doesn't take into consideration the additional rebates Kentucky will receive by taking advantage of  a singular preferred drug list," a system that CVS also takes advantage of, he said, noting that state law requires a pharmacy to dispense the lowest-cost prescription drug products.

As for the dispensing fees, Kupper said Kentucky pharmacists will work with the state to set those rates.

Further, he said, "Given that spread pricing accounted for $123 million in costs last year, we know that the state will save at least that much just by eliminating PBMs from using the practice."

At the bill's March 10 Senate hearing, Stephanie Stumbo of the Kentucky Association of Health Plans did not speak against the bill, but offered a long list of issues that she said needs to be considered as the state moves forward with a plan that hasn't been tested in any other state.

For example, she said it was important that this new model be able to offer real-time pharmacy data to the managed-care organizations to better inform patient care, and that a disconnect between the PBM and the MCOs would likely lead to higher cost.

But for now, legislators like the idea of change. As the House passed the bill unanimously on March 12, Rep. Steve Sheldon, R-Bowling Green, said, "We will provide much needed relief to our community pharmacies in the form of more, fair reimbursements rather than below their costs many times. I believe this structure is adequate enough to fairly compensate providers and also has the potential for millions of dollars in savings in Medicaid costs."

An emergency clause will make the take effect immediately upon Beshear's signature, so the sole PBM will be in place when new managed-care contracts begin Jan. 1.

Landmark bill to overhaul public-health system on governor's desk; companion bills, including budget, await action in Senate

By Melissa Patrick
Kentucky Health News

A bill touted as part of a three-phase approach to create a sustainable solution to local health departments' pension-driven financial crisis has been delivered to Gov. Andy Beshear's desk. The other two parts are in the budget and a bill to change how departments pay their pension costs.

Kentucky health department officials gathered in Frankfort
Thursday, March 5 for passage of House Bill 129 out of the
 Senate. The bill has since gotten final passage in the House
and been sent to the governor. (Photo by Melissa Patrick) 

Allison Adams, president of the Kentucky Health Department Association,  acknowledged that the bill, called the Public Health Transformation Plan, wouldn't solve all of the departments' financial and pension woes, but said it was an important step to take toward improving Kentuckians' health and creating a more equitable funding model.

"The nation is looking at us," Adams said, adding that only a few states have implemented a similar plan, "but not nearly as aggressive and forward thinking as Kentucky has."

Adams said the bill has three main components. First, it prioritizes existing public-health resources to programs and services that research shows will improve the health status of Kentucky, which ranks 43rd for health, according to America's Health Rankings.

"We are looking at putting money where we know it can make a difference and keep people healthy versus waiting till they are sick and then paying for treatment," said Georgia Heise, public-health director of the Three Rivers District Health Department in Carroll, Gallatin, Owen and Pendleton counties. She is a long-time advocate of this new business model.

"There's only nine states that I'm aware of that have looked at doing this kind of thing," Heise said, "and our bill is by far the most aggressive and puts the money in the hands of the local health departments."

Adams said the bill codifies a funding formula based on population and each county's ability to generate revenue through a local health tax. "It makes the funding equitable now across the state," she said, "so that we are rising up the less fortunate counties that don't have the ability to get the resources they need through the public-health tax."

 In other words, departments that have more resources would get less state funding. The state has long had a minimum public-health tax of 1.8 cents per $100 worth of property, with a cap of 10 cents per $100. 

The bill also requires departments to conduct community needs assessments to help set their priorities, which would be funded by federal grants or local tax dollars.

Many health department programs are driven by funding attached to a disease, not to health. Advocates say the new model will allow counties to spend their money on what their community assessment shows is most needed.

"It provides the flexibility of our community dollars, your local dollars to drive the services to what is identified in the community needs assessment," Adams said. "I'm happy for the fact that we are now being directed to put money where we know it is going to make the biggest difference in the future . . . We're being astute to the taxpayers' dollars; we're putting it where it needs to go in order to move the health needle."

A spreadsheet prepared by Adams' group estimates that 14 of the 61 county and district health departments would get less state funding, and the rest would get more, using a formula based on a county's population, its ability to support its health department with its current tax, how many employees the county would need to provide only services required by law, and an estimated increase in environmental fees.

The losses range from $4,812 in Whitley County to a high of about $746,404 for the Lexington-Fayette County Public Health Department.

Randy Gooch, director at the Jessamine County Public Health Department, noted that the spreadsheet has not been adjusted for a limit of 25% on increases in environmental fees, which was added to the bill, but said "As long as they provide the necessary funding through the General Fund to make up the difference of environmental fees, there will be little change in this."

Also, a Senate floor amendment deleted language that would have allowed the state health commissioner to set a higher maximum rate for the tax. If Beshear signs into law as expected, an emergency clause will make it effective immediately.

House Bill 129's sponsor, Rep. Kim Moser, R-Taylor Mill, has said that the departments could be as much as $38.5 million short in making their pension-liability contributions, and that 18 of them, representing 41 counties, "will face fiscal insolvency during the fiscal year 2020 without significant financial and operational changes."

The other two parts of the "three-phase approach" include the budget bill and a bill to change how they pay for their pensions.
 
House Bill 171, sponsored by Rep. Jim DuPlessis, R-Elizabethtown, would change the way health departments, regional universities and quasi-governmental agencies pay their pension costs. It would move them away from the current "percentage of pay" formula and to a model that requires them to pay only what they owe the system, divided evenly over the next 27 years. It passed the House Feb. 13 and is awaiting action by the Senate State and Local Government Committee.

DuPlessis told Kentucky Health News in February that the House wants to help health departments that aren't able to meet their pension obligations, but in order for them to get that help, their counties must have a health tax of at least 8 cents per $100 assessed property value.

The House version of the budget, House Bill 352, includes a line-item General Fund allocation on pages 66-69 for each local and district health department to help pay their pension obligations.

A spreadsheet of health departments and taxes that support each of them is at www.uky.edu/comminfostudies/irjci/Kylocalhealthtaxes.xlsx.

Senate bill to address surprise medical billing now in House

By Jim Hannah
Legislative Research Commission

FRANKFORT, Ky. – Legislation to offer patients some protection from surprise medical bills passed the state Senate Friday.

“There are many factors that contribute to surprise billing,” said Sen. Ralph Alvarado, R-Winchester. “Some will place the blame on insurance companies. Some will place the blame on providers. It all depends on whom you ask. But while we are trying to figure out who to blame, patients are stuck in the middle of the problem – often with large medical bills.”

Alvarado's Senate Bill 150 seeks to stop the practice by requiring insurers to cover surprise billing, sometimes called balanced billing. It happens when a patient receives medical care – often unwittingly – outside of their insurer's network. Subsequently, the doctor or hospital bills the patient for the amount insurance didn't cover.

Alvarado characterized SB 150 as a consumer protection bill. He said surprise billing was a dubious exercise of cost shifting from insurers to patients.

A second provision of SB 150 would require the state insurance commissioner to establish a database of billed health-care service charges. A final provision would provide a dispute resolution program for medical insurers and providers to work out their differences over these out-of-network charges.

Sen. Rick Girdler, R-Somerset, spoke against the bill. He cited a fiscal impact estimate that SB 150 would increase individual premiums for health benefit plans by up to $9 per month.

Sen. Tom Buford, R-Nicholasville, said he voted for the bill because the He noted the self-funded Kentucky Employees’ Health Plan already covers surprise billing for its nearly 265,000 members.

“If we are going to enjoy that benefit, the citizens of Kentucky should share the same,” he said.

Sen. Wil Schroder, R-Wilder, who voted no, said what is needed more is broader reform to empower health-care consumers through such measures as transparent pricing of procedures and drugs.

“Today I filed Senate Bill 265 that I believe offers a better solution in the context mentioned,” Schroder said. The bill has been assigned to the Senate Banking and Insurance committee.

Alvarado said SB 150 wasn’t a hastily drafted bill, but the result of three years of investigation.

“I wish to remind the members of the Senate that a successful bill for surprise billing should only make one group happy – and that is the patients we are trying to protect,” he said. “If other stakeholders are a bit uncomfortable, then we have a good compromise on this issue.”

SB 150 went to the House on a vote of 30-3. Sen. John Schickel, R-Union, cast the only other "no" vote.

Opioid epidemic keeps shadowing Ky. policy, as Senate removes opioids from list of drugs physician assistants could prescribe

By Melissa Patrick
Kentucky Health News

A House bill to let physician assistants prescribe some highly regulated drugs is moving through the Senate, but without application to some highly addictive drugs like oxycodone and hydrocodone, showing how the opioid epidemic continues to influence state health policy.

Rep. Steve Sheldon presents House Bill 135 at the March 3
meeting of the Senate licensing and occupations committee.
(Photo: Legislative Research Commission Public Information)

As amended by a Senate committee March 3, House Bill 135, sponsored by Rep. Steve Sheldon, R- Bowling Green, would allow physician assistants "modified prescriptive authority" for controlled substances in federal Schedules III, IV, and V after the PAs have practiced for a year.

The Senate Licensing, Occupations and Administrative Regulations Committee removed Schedule II drugs, which include a long list of narcotics used for pain management as well as several psycho-stimulants that are used to treat attention deficit hyperactivity disorder, or ADHD -- a condition for which Kentucky has the highest rate in the nation.

Sen. Chris McDaniel, R-Taylor Mill, told the committee that he would not have voted for the bill if the Schedule II drugs had not been removed. He warned, "Know if we come back for Schedule II next year, I will oppose it as vigorously as possible."

McDaniel acknowledged that only a few PAs would likely abuse their Schedule II prescriptive authority, but said that isn't worth the risk because it was only a small percentage of physicians that not so long ago flooded the state with pain pills.

"The damage that they did was monstrous and we're still working to overcome it," McDaniel said. "The fact is, one step toward where we were, for me, is a step too many."

Majority Floor Leader Damon Thayer said likewise: "I thought the bill that came flying out of the House was a bridge too far, and going to Schedule II is not going to fly in the Senate right now, and I hope you don't come back and try it again next year; it won't be received very well by this body."

Andrew Rutherford, vice-president of the Kentucky Academy of Physician Assistants, told the committee that the PAs would keep seeing Schedule II authority.

"Our ultimate goal is always to provide the best patient care we can to our patients, that includes allowing us to practice to our full scope of practice," he said.

Rutherford told the committee that Kentucky is losing its PAs to other states because it does not allow them to practice at their full scope of care. Kentucky is the only state in the nation that does not allow PAs to prescribe any controlled substances.

The bill passed the House 91-1 on Feb. 6, with Rep. Lynn Bechler, R-Marion, voting against it. This was the fourth time the legislation had been filed, and the first time it's gained any traction.

Sen. Michael Nemes, R-Shepherdsville, noted that the Kentucky Medical Association, which has opposed this bill in the past, isn't necessarily for the bill but is "not fighting it."

Asked about its stance on the bill, the KMA told Kentucky Health News in an e-mail that it "continues to have concerns regarding the expansion of prescriptive authority for controlled substances among non-physician groups. KMA did work, however, with the Kentucky Academy of Physician Assistants on House Bill 135 with two objectives in mind – promoting public safety and preserving the 'physician-led team model.' KMA will monitor the progress of this bill and urge that principles such as these be included as the legislative process continues."

Adam Haley, government-affairs coordinator for KAPA, told Kentucky Health News that PAs were still working with lawmakers to try to carve out the Schedule II drugs that are used to treat ADHD.

"We obviously heard loud and clear from our members of Senate leadership in committee that there are strong reservations about some of the opioids in Schedule II, and while we believe the gold standard of care does include full Schedule II authority, we're sensitive to those concerns and are working with those legislators on addressing the issue of some of the psycho-stimulants in Schedule II and whether or not those can be broken out separately," Haley said.

Sheldon, the bill's prime sponsor, noted that 49 states allow full prescriptive authority for PAs and Kentucky would become the sixth state to place restrictions on Schedule II if this bill were to become law.

The KAPA's Rutherford said, "Changing this legislation will allow Kentucky to be more attractive for PA practice and will hopefully keep many of those PAs from going to practice in neighboring states. This would allow for more providers in Kentucky, which we all know is much needed."

The bill includes several restrictions on how PAs can prescribe drugs, and new continuing-education requirements, including a number of required hours related to controlled substances. It also leads to a more accurate account of who actually prescribes drugs; now, all scheduled drugs prescribed by a PA are attributed to the supervising physician.

Under the regulation, PAs would still have to work under the supervision of a physician who would be allowed to limit which controlled substances they can prescribe.

Sen. Paul Hornback, R-Shelbyville, said he supported the bill as a way to increase access to care in rural Kentucky and that he hoped the House bill to expand the scope of practice for nurse practitioners would also pass.

Nurse practitioners have been able to prescribe Schedule II drugs, the highest level of painkillers, since 2006, under the supervision of a physician. HB 286, a bipartisan bill sponsored by Rep. Russell Webber, R-Shepherdsville, would allow them to do that without a supervising physician after four years, if their license is in good standing. The General Assembly approved similar authority in 2014 for non-scheduled drugs. This bill is posted in the House Licensing, Occupations and Administrative Regulation Committee.

Committee approves doctors' bill to regulate lawyers' ads aimed at soliciting clients who take certain prescription drugs

By Melissa Patrick
Kentucky Health News

A bill to regulate plaintiff-lawyer commercials that solicit clients allegedly injured by prescription drugs or medical devices is headed to the state Senate floor.

Sen. Ralph Alvarado explained SB 178 to the Economic
Development, Tourism and Labor Committee. (LRC photo)  

“I’m sure all of you are aware and have seen legal advertisements on television about prescription drugs,” said Sen. Ralph Alvarado, R-Winchester. “They look like an important health alert about the risks associated with a medication, often using the logo of a national health organization like the Food and Drug Administration meant to imply authenticity. . . .  And their goal is simple: It is to alarm the public and lure the consumer into calling a 1-800 number that promises them financial recovery through legal services."

Alvarado, the bill's sponsor, called Senate Bill 178 a "patient protection bill" and told the  Senate Economic Development, Tourism and Labor Committee members that such ads compromise the doctor-patient relationship and potentially put consumers' health at risk

He said the ads target many common drugs, including blood thinners and treatments for diabetes, heartburn, heart disease and certain cancers.

"Consider a scenario when someone abruptly stops taking a blood thinner, for example. Patients can experience a stroke or a transient ischemic neurological event, residual paralysis and in the worst case, death," said Alvarado, who is a physician. "What we're seeing is people will view these ads and stop taking the medication, despite it being the best course of treatment and despite there not being a medical reason for the person to stop treatment."

He cited studies to support his claim, including one that found 58 percent of physicians reported having patients who stopped taking their medications without consulting their doctors after seeing such ads, and said the American Association of Retired Persons has sent warnings and letters to its members to implore them to not stop taking their medications without talking to their physicians first.

Among other things, SB 178 would require advertisers to warn viewers that it is dangerous to stop taking prescribed medications before consulting with a physician; would prohibit the use of a government agency logo in any way that suggests an affiliation; would prohibit ads that solicit legal business from being labeled a "medical alert" or "health alert"; and would protect personal health information from being sold or transferred to someone for the purpose of  soliciting legal services without the written authorization of the patient.

Sen. Ernie Harris, R-Prospect, asked how enforceable the bill was since most of Kentucky is served by out-of-state TV stations. Cory Meadows, deputy executive vice president and the director of advocacy for the Kentucky Medical Association, said this still has to be worked out, but said Tennessee has a similar law and West Virginia is considering one.

"What this comes down to is protecting patient health and safety as well as preserving that relationship," Meadows said. "There needs to be some regulation and oversight around these ads if we don't want Kentuckians to get hurt or further hurt."

Sen. Wil Schroder, R-Wilder, a lawyer, asked why a violation would be a misdemeanor rather than a civil violation with a financial penalty. Meadows said the original idea was a felony, and was negotiated down. He said some criminal penalty was needed to "put teeth" in the bill.

Jay Vaughn of the Kentucky Justice Association, which represents plaintiffs' lawyers, said the group likes the proposed warning to not stop taking a drug without consulting a physician, but thought the other provisions went too far.