A county's poor health status was a strong predictor of its vote for Donald Trump; many examples in Kentucky

There was anecdotal evidence after the presidential election of a correlation between counties that swung big to Donald Trump and those with poor health status. The Economist magazine used a weighted index of obesity, diabetes, heavy drinking, exercise and life expectancy as calculated by the Institute for Health Metrics and Evaluation at the University of Wisconsin, and found a statistical correlation with the difference in Trump's vote and the vote for Mitt Romney in 2012.

"Together, these variables explain 43 percent of Mr. Trump’s gains over Mr. Romney, just edging out the 41 percent accounted for by the share of non-college whites" in a county, which has been widely cited as the best statistical predictor of a swing to Trump. "The two categories significantly overlap: counties with a large proportion of whites without a degree also tend to fare poorly when it comes to public health. However, even after controlling for race, education, age, sex, income, marital status, immigration and employment, these figures remain highly statistically significant. Holding all other factors constant—including the share of non-college whites—the better physical shape a county’s residents are in, the worse Mr. Trump did relative to Mr. Romney."

The correlation is indicated by the slope of a scatterplot of counties on a graph with health status as the X axis (across the bottom) and change in Republican margin from 2012 as the Y axis. The county dots were scaled by size and colored by region. The colors showed that the Midwest made the big difference for Trump.

The chart on the Economist website is interactive, with data for each county. Running a cursor over the gold counties reveals figures on many in Kentucky. The county with the largest Republican swing, 46.6 points, at the top of the chart, was Elliott County, which had never gone Republican in a presidential election. Here's a screenshot with the cursor on Pike County:

Counties that swung Republican by more than 30 percentage points, and had a health index below 30 on a 0-100 scale, with their swing and index, were: Adams County, Wisconsin (30.4, 27.2); Grundy County, Tennessee (34.7, 27.3); Washington County, Missouri (36.2, 29.4). Near-misses were Shoshone County, Idaho (29.2, 30.0); Starke County, Indiana (31.4, 30.6); Juneau County, Wisconsin (33.3, 30.6); and Arenac County, Michigan (28.4, 30.3).

Daily dose of soda pop 'batters' the body's cells and increases pre-diabetes risk 46 percent, study says; 1 in 3 in Ky. may have it

Illustration by superanimalswallpapers.blogspot.com

Drinking a can of sugar-sweetened beverage a day increases your risk of developing pre-diabetes by 46 percent, according to a recent study.

The study by the Jean Mayer USDA Human Nutrition Research Center on Aging  at Tufts University in Boston said the daily dose of sugar "batters a person's body on a cellular level," reports HealthDay.

"This constant spike in blood glucose over time leads to the cells not becoming able to properly respond, and that's the beginning of insulin resistance," senior researcher Nicola McKeown told HealthDay. She added that once insulin resistance starts, blood sugar levels rise to levels that are damaging to every major system in the body.

"As many as one in three Kentucky adults, about 1.1 million people, are estimated to have pre-diabetes, but only 8.6 percent, more than 248,000 people, have reported being diagnosed, according to the Kentucky Department for Public Health and the CDC," Darla Carter of The Courier-Journal reported in an in-depth look at diabetes in Kentucky.

The study, published in the Journal of Nutrition, analyzed 14 years of self-reported data from nearly 1,700 middle-aged adults on their consumption of sugar-sweetened beverages and diet sodas. Participants did not have diabetes or pre-diabetes when they entered the study. The information came from the Framingham Heart Study, a multi-generational study that measures lifestyle and clinical data that contributes to heart disease.

This study found that a can of diet soda every day does not boost pre-diabetes risk, but notes that other studies have found otherwise.

McKeown told HealthDay that results from this study show that cutting back on sugary drinks is "a modifiable dietary factor that could have an impact on that progression from pre-diabetes to diabetes."

The American Beverage Association, a lobby for soft-drink manufacturers, countered that sugar-sweetened beverages aren't the only risk factor for pre-diabetes.

"Credible health organizations such as the Mayo Clinic note that the risk factors for pre-diabetes include factors such as weight, inactivity, race and family history," the industry group said in a statement to HealthDay.

The study said that pre-diabetes risk did decline when other factors such as other dietary sources of sugar and weight were considered, but not by much -- with the increased risk associated with sugary drinks still amounting to about 27 percent.

Best way to diagnose pre-diabetes: A1c hemoglobin

Another study found that the common blood test called hemoglobin A1C is the "most accurate predictor" of who will go on to develop diabetes and to develop long-term complications from it, and says it's time for everyone to agree on the best way to diagnose pre-diabetes.

“The goal is to figure out who is at the highest risk of not only developing diabetes but of developing its serious complications including kidney disease, cardiovascular disease and even death,” lead author Bethany Warren said in the Johns Hopkins Bloomberg School of Public Health news release. “Hemoglobin A1C appears to be the tool that is best able to do that.”

Professional organizations differ on how they define pre-diabetes, a condition that indicates whether a patient is likely to develop type 2 diabetes, says the release. For example, the American Diabetes Association recommends either the A1c hemoglobin test or glucose levels, while the World Health Organization recommends the glucose test only.

Glucose measures look at current levels in the blood as opposed to A1c hemoglobin, which looks at glucose exposure over two to three months.

The one thing health-care providers agree on is that people who are at high risk of developing diabetes can reduce their risk through weight loss, changes in their diet and increased activity. Some even recommend the use of a medication called metformin to reduce the risk.

“When someone is told they have pre-diabetes, we hope it will cause them to make changes to their habits in order to prevent the development of diabetes and its complications,” senior author Elizabeth Selvin, a professor in the Department of Epidemiology at Johns Hopkins said in the release. “Being identified as having pre-diabetes can also make it easier to receive weight loss and nutritional counseling as well as reimbursement for these services.

The study, published in Lancet Diabetes & Endocrinology, found no difference between the two glucose tests used to diagnose diabetes and pre-diabetes, but found that the tests diagnosed pre-diabetes at a higher rate.

"We also don’t want to over-diagnose people," Slevin said. "Using the hemoglobin A1C test allows us to more accurately identify those persons at highest risk.”

Study: Teens who frequent e-cigs are more likely to become frequent smokers; vaping industry disputes conclusions

Teens who use electronic cigarettes regularly are more likely to become frequent and heavy cigarette smokers, according to a new study.

The study, published in the Journal of the American Medical Association, looked at more than 3,000 teens in 10 Los Angeles County public schools who "vaped" frequently and found they were more than twice as likely to start smoking "on about a weekly basis" and twice as likely to smoke more cigarettes on days when they do smoke, HealthDay reports.

"The more you vape, the more likely in the future you're going to be smoking. You're going to be smoking more frequently and you're going to smoke more cigarettes per day on your smoking days," lead researcher Adam Leventhal told HealthDay.

Leventhal is an associate professor of preventive medicine and psychology at the University of Southern California Keck School of Medicine in Los Angeles.

In Kentucky last year, 41.7 percent of high-school students said they have used an electronic vapor product and 23.4 percent said they were currently using one, according to the Youth Risk Behavior Study. Both of these numbers are similar to the national rates of 44.9 percent and 24.1 percent, respectively.

This study, like others, established an association between smoking and vaping, not cause and effect, HealthDay reports. However, the e-cigarette industry criticized the study's definition of "frequent" vaping or smoking as three days or more each month.

"Why? Because despite having a sample size of over 3,000, the authors were only able to identify a fraction of students who had progressed onto any cigarette smoking, let alone actual frequent or heavy smoking," said Gregory Conley, president of the American Vaping Association,

The study surveyed 10th graders in the Los Angeles high schools during fall 2014 and six months later. About 95 percent of the students in the study said they were non-smokers, and about 98.5 percent said they'd never vaped.

However, HealthDay reports: "The kids who did vape were more likely to try cigarette smoking, and more frequent vaping was associated with more frequent and heavier smoking, Leventhal said."

Leventhal suggested this could be because teens will first get hooked on the nicotine in the e-cigarettes and then turn to tobacco for a "stronger fix" or that e-cigs make them familiar with smoking, making it easier to make the switch to traditional cigarettes.

Dr. Norman Edelman, the American Lung Association's senior scientific adviser, agreed that nicotine in e-cigarettes could lead teens to smoke traditional cigarettes and called for stricter regulations of e-cigs, including the ban of any marketing targeted at teens.

Conley countered that "the rise in vaping experimentation has fueled record-breaking declines in teen smoking," reports HealthDay. He added: "It would be public health malpractice to use studies with poorly defined parameters, such as this one, as an excuse to deny adults access to these far safer products."

Ignore the election and shop around for the best deal on subsidized health insurance, columnist advises

While major changes in health insurance seem likely as a result of the election, "That doesn’t mean you should avoid signing up for 2017 insurance coverage," writes Trudy Lieberman of Rural Health News Service. Any changes are unlikely to affect coverage for the coming year, given the constitutional ban on impairing existing contracts.

Trudy Lieberman

While choice on the government health-insurance exchanges is more limited this year, especially in rural areas, Meaning "high premiums and limited options for doctors and hospitals," Lieberman writes. "Some careful shopping is in order to minimize any surprise bills."

Lieberman notes that White House Press Secretary Josh Earnest said “the vast majority” of consumers eligible for Obamacare subsidies would have monthly premiums of $75 or less, but she warns, "That doesn’t mean the vast majority should automatically buy a policy with a $75 premium. That strategy can mean expensive trouble later on. Reviewing the basics before wading into the Obamacare marketplace this year is essential."

Obamacare plans come in four types: Platinum policies, generally the most costly, cover 90 percent of medical costs; gold plans cover 80 percent; silver plans pay 70 percent; and bronze 60 percent.

"Silver plans have been the most popular, largely because those who buy them and have family incomes below $60,750 get extra government subsidies to help pay their deductibles, copays and coinsurance," Lieberman notes. "Bronze policies are popular, too, because they have low premiums, but people buying those policies won’t get the extra subsidies, a point that’s worth remembering. Those subsidies can be a big help if you need a lot of medical services. Both bronze and silver policies generally come with lower monthly premiums, but that doesn’t mean they are cheaper in the long run."

For example, Lieberman writes, "It’s possible a bronze policy and maybe a silver one could end up costing more than a gold one with a higher premium if you get sick. That’s because of the relationship between the premium, co-pays, co-insurance and deductibles. Insurers mix and match these features to fit their marketing strategy. In general, a lower premium means higher deductibles and higher other out-of-pocket expenses. A policy with a higher premium often means lower out-of-pocket costs."

In 2017 the maximum out-of-pocket cost for a family is $14,300. "That’s a lot of money, and enough to deter some people from signing up. Many people say paying that much before insurance pays isn’t really insurance," Lieberman writes. "It’s also high enough to keep people from seeking medical care even when they need it."

Lieberman reports that an Indiana couple she has followed shopped around for coverage after their insurer sent them a notice that their $836 monthly premium would jump to about $1,300 and they would have to pay 50 percent of hospitalization costs instead of 20 percent. Their shopping found them a plan for only $700 a month, she reports.

"Choosing an Obamacare policy or any other insurance coverage comes down to how much risk you want to assume," Lieberman advises. "If you are reasonably certain you won’t need many medical services, you may want to take a chance and buy less expensive insurance that comes with high deductibles, copays, and coinsurance. But if you’re like the Indiana couple, and afraid of high expenses for unexpected medical care, buy the best policy you can afford that reduces that risk."

Lieberman invites consumer to share their insurance-shopping experiences with her at trudy.lieberman@gmail.com.

Drug overdoses in Northern Kentucky skyrocketed after arrival of super-potent fentanyl and carfantenil

Drug overdoses in Northern Kentucky have skyrocketed as the super-potent opioids fentanyl and carfantenil have been added to the heroin supply, Terry DeMio reports for The Cincinnati Enquirer.

"In just three months, August, September and October, emergency caregivers at the Northern Kentucky hospitals [of St. Elizabeth Healthcare] reversed 692 overdoses, which is 60 percent of the number of overdose-reversal cases in all of 2015," 1,168, DeMio reports. "The powerful synthetic opiates have been responsible for increasing overdose deaths in the region and the nation. Carfentanil is the large-animal tranquilizer that law enforcement first identified" in Cincinnati in July.

Ashel Kruetzkamp, nurse manager for St. Elizabeth Edgewood's emergency department, told DeMio, "A patient stated they used heroin, but they really don’t know what they are getting. Is it pure heroin or has it been cut to intensify the effect of the drug?" Kruetzkamp said she only counts the cases in which the victim admits to using heroin, so some heroin-related overdoses probably went unrecorded, DeMio notes.

St. Elizabeth recorded a record 308 overdoses in September, but emergency calls for overdoses in Northern Kentucky seem to have slowed since. "We are starting to see a slight decrease since September’s spike," Kruetzkamp told DeMio. "We still have too many overdoses related to this opiate epidemic in our community each and every day."

How Republicans and Democrats can come together to fix Obamacare, at least in one journalist-professor's opinion

President-elect Donald Trump has said he wants to keep requiring health-insurance companies to cover people with pre-existing conditions, but knowledgeable observers say that would still require all Americans to buy insurance and require insurers to sell policies to everyone in the same geographic area for roughly the same price, notes Steven Pealrstein, business reporter and columnist Steven Pearlstein of The Washington Post and Robinson Professor of Public Affairs at George Mason University.

Steven Pearlstein

"It would be wrong, however, for Democrats to jump from that observation to the conclusion that there aren’t other ways to structure a health insurance market to achieve near-universal coverage at affordable prices," Pearlstein writes. "Republicans have proposed a number of credible reform ideas that could preserve most of the gains from the Affordable Care Act while restructuring the system to better conform to conservative, market-oriented principles. A few would even make the system more efficient and more progressive."

Pearlstein says those approaches "would induce more of the young and healthy into the market with lower premiums, even as premiums rise for those who are older and sicker." Several companies have pulled out of the market for Obamacare policies subsidized by tax credits because too many young people are choosing to pay the relatively modest penalty for not having insurance instead of paying premiums that they consider too expensive.

Other Republican ideas "would abolish many of the health law's taxes and reduce federal regulation of insurance markets while preserving some but not all of the premium subsidies for the poor and working class," Pearlstein reports.

"The most interesting and radical of the Republican reform ideas is to eliminate the tax-free treatment of employer-paid health insurance and use the $260 billion in increased revenue to give tax credits for every American to offset the cost of buying health insurance," proposed by Arizona Sen. John McCain in his 2008 presidential campaign and endorsed by some other Republicans, Pearlstein writes.

"The current exclusion is the largest and one of the most regressive tax breaks in the current income tax code. The biggest benefits go to people who have the highest incomes and have the most expensive health insurance policies, while people who are unemployed or work for employers who don’t offer health insurance don’t get any tax benefit at all. The only justification for such a regressive and inefficient tax is a political one: eliminating it would trigger fierce political opposition from big business and big labor.

"In these proposals, the tax credit would be adjusted by age and income and be sufficient to allow those with median incomes or lower to buy 'catastrophic' insurance that would cover major medical incidents. Individuals and their employers would be free to supplement the catastrophic policy and buy another layer of more comprehensive coverage but only with after-tax dollars. Or they could put additional money in a tax-free health savings account to pay for routine medical care not covered by insurance. The government could deposit additional money in the health saving accounts of lower-income households.

"By tying the level of the tax credit to the cost of catastrophic insurance, a well-designed Republican 'replacement' could make it possible for all Americans to afford less-expensive basic coverage without resorting to a mandate. Surely this is a framework that Democrats should be able to work with as an alternative to the Affordable Care Act, which relies instead on an individual mandate, premium subsidies for the poor and working class and a 'Cadillac tax' on gold-plated insurance policies. Like Obamacare, it would require insurers to sell policies to everyone at the standard rate, albeit with greater variation based on age. Unlike Obamacare, the structure of the tax benefits would be progressive rather than regressive.

"Democrats at this point will surely complain that catastrophic insurance is unacceptable because it leaves households responsible for paying thousands of dollars for routine medical bills until insurance kicks in. After all, a lot of people resent large co-payments and deductibles, even if they lower premiums. And there is evidence that if low-income households are required to pay anything out of pocket, they will not get necessary preventive or routine medical care, putting them at risk for getting seriously sick later on.

"But there is equally compelling evidence that when people have health insurance that covers any and all medical expenses, they act like hungry football players at an all-you-can-eat buffet, consuming much more health care than they need, irrespective of cost, driving up health insurance premiums for themselves and everyone else. When people pay for routine health care the way they pay for other necessities, they are more likely to buy only what they need and shop around for the best value.

"Both sides in this debate overstate their case. Democrats have a bad habit of assuming that people — particularly poor people — aren’t smart enough to figure out how to best spend their health-care dollars without guidance from the nanny state. At the same time, the Republican case for “consumer-driven” health care overstates the degree to which most of us are willing or able to shop for value. When it comes to medical care, our instinct is to think that low price means low quality. (Would you go to surgeon who advertises, “Special This Week Only! Hip Replacements: Two for the Price of One!) And how are we supposed to shop for value when lying half-conscious in the back of an ambulance?

"Given the political realities, Democrats should be willing to accept a system built around high-deductible insurance as long as such policies also cover proven preventive care and treatment of chronic conditions. In exchange for expanding the role of tax-free health savings accounts, Democrats could insist that the accounts of low-income families receive government subsidies to cover a significant share of their out-of-pocket medical expenses.

"In exchange for going along with the Republican push for 'consumer-driven' health care, Democrats could insist that consumers have the tools they need to make good decisions. Doctors, hospitals and drug companies could be required to provide clear, simple information on prices and quality. Providers could be prohibited from charging more for individuals paying their own bills than they charge the largest insurance company. And to ensure a genuinely competitive market, rather than the fake one we have now, Democrats could demand stepped-up antitrust enforcement against hospitals, insurers and drug companies, while taking away from medical associations the power to limit the supply of physicians and prevent nurses from performing routine tasks.

"In exchange for hard caps on insurance industry profits and administrative costs, insurers could be required to disclose how much of every premium dollar goes to pay for medical services. And in exchange for less federal control, state regulators could be given the option to maintain as much of the Affordable Care Act architecture as they chose.

"Inevitably, some laudable features of Obamacare will be lost in a bipartisan compromise. Elections matter. But it’s worth remembering that President-elect Donald Trump and his Republican allies will be as desperate to show they can make good on their promise to painlessly repeal and replace Obamacare as Democrats are desperate to preserve it as is. Democrats can leverage that reality to their advantage. Rather than simply demonizing all Republican ideas and rejecting them out of hand, Democrats might do well to acknowledge the changed political environment and negotiate a better alternative to the Affordable Care Act than the one the Republican Congress will deliver if forced to rely on the votes of their most conservative members."

Teen birth rates are declining faster in urban counties than rural ones, nationally and in Kentucky

By Melissa Patrick
Kentucky Health News

Kentucky's teen birth rates are dropping faster in its urban counties than in its rural counties, a trend that has also been found across the nation, according to the federal Centers for Disease Control and Prevention.

A CDC report looked at the differences between teen birth rates in rural and urban areas from 2007 to 2015 and found that among teens ages 15 to 19, birth rates in Kentucky's urban counties dropped 43.9 percent, and 31.8 percent in its rural counties. Both lagged the national decreases; teen births in the U.S. dropped 47.6 percent in urban counties and 37.1 percent in rural ones during the period.

In Kentucky, the teen birth rate in urban counties was 26.4 births per 1,000 females in 2015, a reduction of 44 percent from the 47.1 reported in 2007. The state's rural teen birth rate was 40.9 per 1,000 in 2015, a 33 percent reduction from the 60 per 1,000 in 2007.

While teen birth rates have dropped significantly in Kentucky in recent years, they remain higher than the national average. Kentucky's teen birth rate in 2015 was 32.4 per 1,000, almost half again as much as the national average of 22.3 per 1,000.

Nationally, in large urban counties teen birth rates fell 50 percent between 2007 and 2015, 18.9 births per 1,000. The rate dropped 44 percent in small to medium-sized urban counties, to 24.3 births per 1,000; and 37 percent in rural counties, from 49.1 to 30.0 per 1,000.


The report didn't explain why teen birth rates have decreased more in urban areas, but in 2015 the National Campaign to Prevent Teen and Unplanned Pregnancy issued a report that tried to explain the disparities, Sarah Frostenson reports for Vox.

It found that teens in rural areas have reduced access to health services that offer contraception, have fewer college opportunities, have higher uninsured rates, have higher poverty rates and have fewer "positive recreational outlets," which is associated with increased risk taking.

"Disparities in the teen birth rate, which we believe mirror disparities in the teen pregnancy rate, are largely explained by differences in economic opportunities and access to health care, including access to contraceptive services," says the report.

In Kentucky, teens in rural counties have access to contraception at local health departments, which can provide a broad range of contraceptive choices to teens without parental consent. However, the National Campaign report found that rural teens often face transportation barriers.

"All adolescents receiving family planning services in the local health department receive counseling on family involvement in decision making (regardless if a parent is present or not), avoiding sexual coercion and abstinence as the healthiest contraceptive choice for teens," according to an e-mail from the Department for Public Health's Division of Women's Health.

Another challenge facing Kentucky teens is a possible lack of reliable information about sex because the state only requires abstinence be taught in the classroom during mandated sex education classes (an approach that has been proven ineffective) and doesn't require a set curriculum for fact-based, comprehensive sex education.

The CDC report also showed disparities by race and geographic location.

It found that in 2015, birth rates among white teens was lowest in large urban counties, but about 2.5 times higher in rural counties than in large urban ones (10.5 and 26.8 per 1,000 respectively). It found that teen birth rates among Hispanic teens (34.1 per 1,000) and black teens (29.1 per 1,000) were higher than the white teen rate and that birth rates for both of these groups were even higher in rural counties, 39.6 per 1,000 births for black teens and 47 per 1,000 for Hispanic teens.

Sitting for long periods while traveling increases risk of blood clots, which can be deadly; moving around can prevent them

 everydayhealth.com

Holiday travel often involves things you can't control, such as delayed flights, traffic jams and inclement weather, but there is a health condition you can prevent just by getting up and moving around.

It's called deep vein thrombosis, or DVT, and it's associated with long periods of sitting while traveling, either by car or airplane. DVT occurs when a blood clot forms deep in a vein, most commonly in the legs. "The clot can travel unnoticed through the blood stream and lodge in the brain, lungs, heart and other areas causing severe damage to organs, and in some cases, death," says a release from Houston Methodist Hospital.

“The last thing we think about when we are going to see loved ones for the holidays is DVT,” Alan Lumsden, chief of cardiovascular surgery at Houston Methodist DeBakey Heart & Vascular Center, said in the release. “But it’s a very serious condition that can simply be avoided by getting up and moving around.”

Lumsden offers some tips to avoid DVT while traveling:

• Get up and walk around at least every two hours
• Don't sleep more than four hours at a time
• Stay hydrated
• Wear loose-fitting clothes
• Eat light meals and limit alcohol consumption
• Wear compression stockings, especially if you have known circulation problems or are elderly

He also notes that if you aren't able to get up every couple of hours, you should do the following exercises while sitting down.

• Extend both legs and move both feet back and forth in a circular motion.
• Move the knee up to the chest and hold the stretch for at least 15 seconds.
• Put both feet on the floor and point them upward.
• Put both feet flat and lift both heels as high as possible.

“Symptoms include pain and tenderness, swelling, redness, and increased warmth in one leg,” Lumsden said. “In some cases, a physician might suggest that a patient go on blood thinners or simply take an aspirin before and during a long trip to avoid DVT.”

About 2 million Americans are diagnosed with DVT every year and nearly 200,000 die, says the release. It is most common in those over 60, but can occur in any age group. Lumsden added that pregnant women and those who have a history of heart disease, cancer or blood clots should always consult with their health care provider before traveling long distances.

Study finds 78 percent of Kentucky adults on Medicaid have coverage through expansion, most of them young adults

Medicaid covered almost 636,000 adult Kentuckians in the second quarter of this year, with the great majority of enrollees covered under Medicaid expansion and almost half of them young adults, according to a report done for the Foundation for a Healthy Kentucky.

The report found that 493,199, or 78 percent, of the 635,747 Kentucky adults covered by Medicaid were covered by the Patient Protection and Affordable Care Act's expansion of the program to those who earn up to 138 percent of the federal poverty level. The remaining 142,548 were covered by traditional Medicaid.

Almost half (46.5 percent) of the newly covered expansion population were young adults between 19 and 34, the report says. The same age group comprised the largest portion of traditional Medicaid enrollees.

"Medicaid expansion was most important for younger Kentucky adults," Ben Chandler, president and CEO of the foundation, said in a news release. "This tends to be the healthiest population, but if they lose insurance, they're not likely to take advantage of the preventive care that will help keep them healthier throughout their lives. Moving forward, then, the goal has to be keeping them insured."

That goal may face obstacles if President-elect Donald Trump goes through with his promise to repeal health reform, though now he says he wants to keep parts of it.

Gov. Matt Bevin says the state can't afford to pay for the expanded Medicaid population after Jan. 1, when Kentucky taxpayers will start paying for the expansion: 5 percent in 2017, rising in annual steps to the law's limit of 10 percent in 2020.

Bevin has asked the federal government to let the state require Kentucky beneficiaries to pay monthly premiums and require non-disabled recipients to work or do community service. The proposal says this plan "is expected to save taxpayers $2.2 billion over the five-year waiver period," by reducing enrollment in the program, but only $331 million of that would be state tax money, because the federal government covers the bulk of Medicaid costs. The plan is currently under negotiation with federal officials.

The report on Medicaid enrollment comes from the State Health Access Data Assistance Center at the University of Minnesota, which the foundation is paying more than $280,000 to study the impact of the ACA over three years. This study shows a quarterly snapshot of April, May and June 2016.

The report also found that the distribution of the Medicaid expansion enrollment across Kentucky remained virtually unchanged from the third quarter of 2015, with 30.7 percent in Eastern Kentucky, 25.8 percent in Western Kentucky, 19.6 percent in greater Louisville, 16.4 percent in greater Lexington and 7.5 percent in Northern Kentucky.

Kentucky rises to No. 3 in diabetes, increasing concern about removing dental and vision coverage from basic Medicaid

Gov. Matt Bevin's plan for Medicaid "would have a profound effect in a state with the nation's third-highest rate of diabetes," The Courier-Journal reports, because it would remove dental and vision care from the regular package of benefits.

Reporter Deborah Yetter cites a Louisville optometrist who often discovers diabetes during routine eye exams, and an Eastern Kentucky dentist who "is seeing many more patients thanks to Kentucky's 2014 expansion of Medicaid that added coverage for those he describes as the 'working poor'."

"Dr. Bill Collins, a dentist and president of the Kentucky Dental Association, sees many patients with diabetes, which can worsen oral health," Yetter writes. "Some patients are in such bad shape they must have all of their teeth extracted" because, he said, they have gone "so many years without care and without insurance."

Kentucky had the nation's sixth highest diabetes rate until Friday, when the federal Centers for Disease Control and Prevention issued figures for 2015 and ranked the state third.

"The percentage of adults with diabetes went from 11 in 2014 to 12 in 2015, the statistics show, as the state continued to struggle with the disabling and potentially fatal disease. Only Mississippi (14) and West Virginia (13) had higher percentages," Yetter reports. "Moreover, diabetes rates among those on Medicaid are nearly double that of the rest of the population, according to a 2015 state report" based on 2013 figures.

Dentists and optometrists asked Bevin not to remove dental and vision coverage from basic Medicaid, "arguing visits to the dentist and eye doctor are often the first step in identifying more serious health conditions, including diabetes," Yetter notes. "But the administration made only slight changes to its proposal, allowing dental and vision benefits only for the first three months of Medicaid coverage." Afterward, dental and vision benefits would be optional, "available only through a 'rewards' program where Medicaid members can earn points to pay for them through activities such as work or volunteering."

Cabinet for Health and Family Services spokesman Doug Hogan told Yetter there would be several "easy ways" for Medicaid members to gain dental and vision coverage, including weight-loss programs and classes about diabetes.

Hogan "said Bevin's proposal was designed to mirror commercial health plans, which do not typically include dental and vision benefits," Yetter writes. "And Medicaid does not require dental and vision benefits to be included."

Bevin's proposal to the federal government "also promotes moving many people off Medicaid to commercial insurance through their employers," Yetter notes. "Collins said the problem with the governor's plan is that many of the adults added through the expansion work at low-wage jobs that don't offer health insurance."

"I don't think they understand who they are trying to take off," Collins told Yetter. "These are the working poor. You're taking off working people who are trying to make a living."

Yetter writes, "Collins said diabetes is especially problematic for people with poor oral health because it makes them more susceptible to infection, tooth decay and other oral diseases. Such patients require careful monitoring and access to regular dental care, Collins said. Without it, he worries Kentucky will never drag itself up from its low rankings in tooth decay and its high rate of toothless adults - for many a barrier to jobs or well-paying jobs."

"I know something has to be done to address the Medicaid funding," he told Yetter. "But we need to find ways to fund it."

The 2014 expansion made anyone in a household with income up to 138 percent of the federal poverty level eligible for Medicaid. Before that, Yetter notes, "Medicaid was limited to very poor pregnant women and children, disabled people and low-income elderly in nursing homes."

The federal government is paying the full cost of the expansion through Dec. 31. On Jan. 1, the state will begin paying 5 percent, rising in annual steps to the federal health-reform law's limit of 10 percent in 2020. Bevin says the state can't afford the cost.

Ideas for patient safety: collaboration, transparency, more nurses in hospitals and nursing homes, surgical patients' risk awareness

By Melissa Patrick
Kentucky Health News

Patient safety was the topic at the 2016 HealthWatch USA conference this month in Lexington, with health advocates calling for a more collaborative and transparent health-care system to better prevent medical errors, improved nurse-to-patient ratios and a call for patients to become their own advocates to improve their safety in the operating room.

Former surgeon general Joycelyn Elders, professor emeritus of pediatric endocrinology at the University of Arkansas, said preventable medical errors are the third leading cause of death in the U.S., behind heart disease and cancer, and the errors cost the nation "billions of dollars each year." The latest study says between 200,000 and 400,000 Americans die each year from preventable medical errors, she said.

"You will find very few death certificates that will have medical error on them," she said. "That is not the culture that we have. . . . but we've got to change the culture."

Elders said to increase patient safety in hospitals, we have to create a culture of transparency and open reporting; that hospitals need to create systems of collaboration that allow for transparency; and that these systems must be "consistent and persistent" in these efforts.

Daniel Saman, research scientist at the Essentia Institute of Rural Health in Minnesota, talked about the rising cost of care, noting that while the U.S. pays more for care than most developed nations, its life expectancy is lower, its infant mortality rate is higher, the number of people over 65 with two or more chronic conditions is higher, and its obesity rates are higher than those countries'.

Saman, chief epidemiologist for HealthWatch USA, said the increased cost of care in the U.S. is largely driven by high administrative costs, high drug prices and increased use of medical technology, rather than more frequent doctor visits or hospital admissions.

Said Abusalem, an assistant professor in the School of Nursing at the University of Louisville, talked about building a culture of safety in health care, especially in nursing homes, through appropriate staffing, improved communication systems, non-punitive responses to mistakes and effective leadership.

"You cannot talk about patient safety without talking about the culture of safety," he said.

He noted that most adverse events in nursing homes are related to falls and pressure ulcers. He said 6 to 25 percent of nursing-home patients have pressure ulcers, and the annual rate of falls in the homes is 1.7 per bed, with 10 to 25 percent of the people who fall sustaining serious injuries resulting in death.

Abusalem discussed his study, "In an Era of Reform: The Culture of Safety in Long-Term Care Facilities." He found nursing homes that reported good teamwork had fewer pressure ulcers and fewer falls; nursing homes with better communication systems had fewer falls; and those that staffed more hours with registered nurses had fewer pressure ulcers.

As the number of RNs plus licensed-practical-nurse staff hours per resident per day increased, the rate of falls decreased by 79 percent, he said, noting "This is a very significant finding."

He added: "As the culture of safety scores increased, the risk of falls decreased 26 percent, UTIs [urinary tract infections] decreased 20 percent and the short-stay ulcers decreased 7 percent. So the more culture of safety, the less the adverse risk for our residents in nursing homes."

He said his study shows the need to build a strong culture of safety in nursing homes to promote employee retention and the value in hiring RNs to improve safety.

Nurse-to-patient ratios can be critical

Texas RN Deena Sowa McCollum said a series of delays in her father's care, despite her strong advocacy, contributed to his death in 2015.

McCollum said she had worked in leadership positions for 11 years and thought she was in tune with the needs of her nurses, but after her father died, she had to return to bedside nursing to try to figure out the shortcomings in the system. "I needed a better understanding of why so many things could go wrong for one person," she said.

McCollum said she had no idea that higher rates of errors were associated with nurse-to-patient ratios above 1:5. Now she knows that for every patient above five assigned to a nurse, there is a 7 percent increase in error.

"When I have six patients, I know my patient. I know their medications and their diagnosis. I may know a family member, but probably not. And I will have to be very deliberate at making sure that I catch subtle changes because we are so easily disrupted with tasks," she said.

"When I have seven or eight patients, which is the norm -- 90 percent of the time I have seven or eight patients on a med-surg kind of floor-- they all start looking alike. I spend a great deal of my time prioritizing who is the sickest and who is the most unstable and what do I need to do for them. I don't always remember why they are in the hospital or what medications they are on. I often know them by room number and that is embarrassing to say. I am going to miss subtle changes and I am going to make medication errors. The patient that is going home that needs a lot of discharge instructions, I am barely going to see them."

McCollum cited research from California that found the difference between a 1:4 and a 1:8 nurse-to-patient ratio is approximately 1,000 deaths a year. She added that adding one patient to a nurse's workload increases the odds to readmission for heart attack by 9 percent, heart failure by 7 percent and pneumonia by 6 percent. Patients on an understaffed unit have a 6 percent higher mortality rate.

She said legislation to establish a safe nurse-to-patient ratio is in the works and that though some states have instituted such practices, they are not well-monitored. She noted that nurses will gather in Washington, D.C., May 4-5 in support of legislation for better nurse-to-patient ratios.

A Massachusetts Nurses Association survey from 2015 found that 50 percent of the nurses in the survey reported injury and harm to patients due to understaffing; 61 percent reported medication errors due to unsafe patient assignment; 61 percent reported complications for patients due to unsafe staffing assignments; 81 percent report RNs don't have enough time to educate patients and provide adequate discharge planning and 86 percent report RNs don't have time to properly comfort and care for patients and families due to unsafe staffing assignments.

Operating room safety

Dr. Mark S. Davis, an operating room safety consultant and author of Irresponsible: What Surgeons Won't Tell You and How to Protect Yourself, said there are hidden risks to surgeries that put you at risk of contracting HIV or hepatitis C because many surgeons don't adhere to basic safety standards.

"This risk does not appear on a surgical consent form and is not discussed pre-operatively with the patients," he said.

He said surgeons and assistants are "injured with needles, scalpels and other sharp objects at an astonishing 1,000 times a day" and are exposed to the blood of potentially infected patients because many people are infected with HIV or hepatitis C and don't know it.

Davis said that surgeons usually fail to report their injuries and that this puts their future patients at risk because if they are infected and don't know it (and might not know it for years), they can then transmit the infection to a healthy surgical patient during a procedure if they cut themselves and then bleed into the patient.

Davis said most exposures are preventable if physicians would use safety devices to prevent sharps injuries, like safety designed injection equipment, safety scalpels and blunt tipped suture needles. Federal law requires surgeons to use them, but there is a clause in the law that says surgeons may chose to not use them if "in their opinion, they interfere with patient care."

"Well the truth is, they rarely interfere with patient care. I have a lot of experience with them, yet only 5 to 10 percent of surgeons use these devices," Davis said.

He said surgeons don't use them because of the poor enforcement of the federal regulations that requires them; because facilities don't enforce their use; and a general resistant to change.

"The only solution left in my mind is consumer pressure," he said.

Davis stressed the importance of bringing someone with you to your appointments to ask questions and assure understanding and said there are some questions that "you can and must ask" the surgeon before you schedule any surgery to protect you from this hidden risk:

1. Do you use blunt tipped suture needles to close your incisions?
2. Do you use a neutral zone for passing sharps?
3. Do you double glove?
4. Do you and your team all use protective eyewear?
5. Do you use safety scalpels?

"As a consumer of health care, you have the power to protect yourself and you must use that power," he said.

Election results increase concerns among supporters of Medicaid expansion in Kentucky

The election of Donald Trump and continued Republican control of Congress have compounded worries about the future of health care for the 440,000 Kentuckians who gained it from the expansion of Medicaid, especially those in depressed rural areas, Phil Galewitz reports for Kaiser Health News and NPR.

Gov. Bevin and President-elect Trump (Courier-Journal montage)

On top of Gov. Matt Bevin's request for changes in Medicaid, Trump and a Republican Congress are poised to repeal the health-reform law that allowed the expansion and perhaps give states much more leeway in running the program.

"The Medicaid expansion under Obamacare in Kentucky has led to one of the sharpest drops in any state's uninsured rate, to 7.5 percent in 2015 from 20 percent two years earlier," Galewitz notes. "Bevin has threatened to roll back the expansion if the Obama administration doesn't allow him to make major changes, such as requiring Kentucky's beneficiaries to pay monthly premiums of $1 to $37.50 and require non-disabled recipients to work or do community service for free dental and vision care."

Bevin has said the state can't afford to have 30 percent of its population on Medicaid after Jan. 1, when Kentucky taxpayers will start footing part of the bill for the expansion: 5 percent in 2017, rising in annual steps to the law's limit of 10 percent in 2020.

"Trump's unexpected victory may help Bevin's chances of winning approval," Galewitz writes. "Before the election, many analysts expected federal officials to reject the governor's plan by the end of the year on the grounds that it would roll back gains in expected coverage."

The outgoing Obama administration may be willing to approve changes it wouldn't have otherwise, in order to maintain the expansion in a state it has often cited as a health-reform success story. But the administration could also leave the decision to Trump appointees, who would be more likely to approve the waiver.

"I think it's much more likely that a waiver could be approved under the Trump administration," said Emily Beauregard, executive director of Kentucky Voices for Health, a collection of advocacy groups that oppose most of Bevin's proposals on grounds that they could reduce access to care. "On the other hand, I wonder if the waiver will be a moot point under a Trump administration, assuming that major pieces of the [law] are repealed," she told Galewitz.

Medicaid helps Freida Lockaby. (Photo by Phil Galewitz)

Galewitz's object example is Freida Lockaby, "an unemployed 56-year-old woman who lives with her dog in an aging mobile home in Manchester" and got her first health insurance in 11 years from expanded Medicaid. "It's been a godsend to me," she told Galewitz. "I am worried to death about it."

"Lockaby finally got treated for a thyroid disorder that had left her so exhausted she'd almost taken root in her living room chair. Cataract surgery let her see clearly again. A carpal-tunnel operation on her left hand eased her pain and helped her sleep better. Daily medications brought her high blood pressure and elevated cholesterol level under control," Galewitz writes. "But Lockaby is worried her good fortune could soon end."

So is Ramiro Salazar, 47, another unemployed resident of Manchester. "With Medicaid, he sees a doctor for his foot and ankle pain, meets regularly with a psychologist for anxiety and gets medications — all free to him," Galewitz writes. "Medicaid even covers his transportation costs to doctors, vital because a specialist can be 40 miles away. Salazar is worried about Bevin's plans, especially the additional costs."

"I probably couldn't afford it," he told Galewitz. "It would hurt me pretty bad."

Dr. Jeffrey Newswanger, the chief medical officer at Manchester Memorial Hospital, "sees both sides to the debate over Medicaid," Galewitz writes.

"Just because they have a Medicaid card doesn't mean they have doctors," so they are using the hospital's emergency room, which saw its rate of uninsured patents drop to 2 percent from 10 percent in 2013, the year before the expansion, he told Galewitz.

"Eliminating the expansion altogether would be painful for the hospital and a disaster for the community," Newswanger said. But he added that he appreciates some of Bevin's proposals, which he said should encourage people to get care in less expensive places: "No one values something that they get for free."