Annual study of Ky. kids' well-being looks at role of race, income and location; includes lots of county-level data, graphics maker

By Melissa Patrick
Kentucky Health News

The annual Kentucky Kids Count report has measured the overall well-being of Kentucky's children for 26 years, but this year's report digs deeper and looks at influences of family income, race and location on these measures, and finds that they matter.

“We need to continue to implement policies and practices that help all children, and in order to do that, we must face some uncomfortable truths," Terry Brooks, executive director of Kentucky Youth Advocates, said in a news release. "One of those truths is that the ZIP code in which children live, the amount of money their family earns, and the color of their skin are pervasive and powerful influences on the childhood they will have and the future they can embrace."

The report paints a vivid picture of what Brooks refers to: "We know that a toddler growing up in a rural southeastern Kentucky county will have different opportunities than a toddler growing up in the suburbs of Northern Kentucky, just like a young girl whose family is in deep poverty will have different life experiences than a young girl whose family is financially stable. And a black teenager will experience high school differently than his or her white peer."

Overall child well-being: Counties grouped from high to low

The Kentucky counties with the highest overall child well-being are Oldham, Boone, Spencer, Woodford, and Ballard. Wolfe, Clay, Martin, Owsley and Lee counties scored worst.

The report, released Sunday by KYA, is part of the 26th annual release of the County Data Book, which ranks every Kentucky county on overall child well-being through 16 measures in four areas: economic security, education, health and family, and community strengths. 

The report notes that the 2016 report can only be compared to the 2015 report because of changes made last year. Click here to see the full report. Click here for the Kids Count Data Center for access to national, state and county data.

Most of the 16 indicators didn't change much from last year, but the report found that income, race and location influenced every area of child well-being measured in the study. The report gives a detailed overview of these findings and offers solutions to address them.

Economic security

More than one in four Kentucky children live in poverty: 26 percent. In several counties, the figure is more than 50 percent.

The report found that the state's young children, those in Eastern Kentucky, and black and Hispanic children have a higher chance of living in poverty.

"There are several reasons why these groups face additional challenges in financial stability such as the high cost of child care for families with young children, job losses due to declining industries, and historical discrimination that prevented black and Hispanic families from building wealth and assets," the report says. The study noted that race is a strong indicator of childhood poverty, with black and Hispanic children more likely to experience deep poverty, and to live in a neighborhood with concentrated poverty.

The report calls for "enhanced income and earning potential, building assets and rewarding personal responsibility through work supports" to help families find their way out of poverty. But it also lists specific legislation to decrease poverty, including paid family leave, a refundable earned-income tax credit, expanding access to child-care subsidies and limiting jail time for parents who have committed minor offenses to allow them to keep their jobs and support their families.

Education: rural-urban disparities

For more than 20 years, Kentucky has made gradual, steady progress on the percentage of fourth graders who are proficient in reading, which is important because studies show that a child who struggles to read proficiently in fourth grade is less likely to graduate. That trend continues, as the number of fourth graders not proficient in reading dropped to 44 percent in 2015-16 from 48 percent in 2014-15.

The rates varied greatly across school districts. The study also found that low-income children were half as likely as their higher-income peers to be proficient in reading by the fourth grade and that black and Hispanic students face greater barriers to reading proficiency.

The report also found that half of kindergarten students still don't meet the standards that define "readiness to learn." This measure is also influenced by income; 60 percent of low-income three- and four-year-olds in Kentucky are not in pre-school.

Young children in rural areas are less likely to attend an early-childhood learning program than those in urban areas, and "Research shows that children living in rural areas who start kindergarten with lower levels of reading achievement are more likely to fall behind their suburban and urban counterparts by third grade, even when controlling for household income," the report says.

The report calls for communities to recognize and support parents as children's first teachers, prevent summer learning loss and keep children healthy, which aids learning. It also suggests improved teacher training, more help for students and limiting discipline practices that remove children from the classroom. In addition, it calls for policymakers to increase investments in high-quality early learning programs, with a focus on reaching children who need it the most.

Fewer teen births, but smokers are a problem

The good news is that Kentucky's teen birth rates continue to drop, to 37.9 teen births per 1,000 in this year's report, compared to 40.6 per 1,000 last year.

But the report also points out that 8.7 percent of Kentucky's babies are born with a low birthweight (less than 5.5 pounds) and that Kentucky has the second highest rate of births to mothers who smoked during pregnancy (21.5 percent), a known cause of low birthweight. Kentucky has the nation's second highest smoking rate, 26.5 percent.

The report calls for tobacco-prevention programs for youth, smoking-cessation programs for pregnant women, and strong smoke-free workplace ordinances to reduce the rates of low-birthweight babies.

"Infants born at a low birthweight are more likely to face short- and long-term health complications and are 25 times more likely to die within their first year of life than those born at a normal weight," says the report, adding that it is "also associated with impaired cognitive development, which impacts educational success, regardless of socioeconomic status."

In Kentucky, the percentage of low-weight babies ranges from a low of 5 percent in Carlisle County, on the Mississippi River, to a high of 14 percent in Lee County, with the highest rates found in Eastern Kentucky. Babies born to low-income mothers are also more likely to have low weight.

The Kids Count Data Center can display comparative historical data for up to seven counties. Here's a multi-line graph of births to smoking mothers in the Lake Cumberland region since 2004-06.

The graph shows that all seven have all exceeded the state average of births to smoking mothers, that Russell County has always led the group of seven, and that its rate has gradually declined since a jump a decade ago.

Family and community: crime and dropouts hurt

The report found that more than one in 10 Kentucky children have lived with a parent who has served time in jail or prison, the highest rate in the nation.

It also found that over the past 10 years, the share of Kentucky children whose head of household has at least completed high school has steadily increased. However, in 17 counties, at least one in four births was to a mother who did not complete high school.

"The more education parents have, the more likely their children are to be prepared for school, to succeed academically and complete high school by age 20, and the less likely they are to be born at a low birthweight, engage in unhealthy behaviors, and become a teenage parent," the report says.

The report noted that adults in rural areas have consistently had lower educational levels and are more likely to be poor, regardless of education level, than those in urban areas; low educational levels are strongly linked to low incomes; and black and Hispanic children in Kentucky are more likely to live in a family where the head of household lacks a high school diploma.

The report calls for Kentucky to utilize a two-generation approaches that address both the needs of parents and children to help them attain needed educational levels and increased economic stability. It also called on workforce development efforts to provide benefits that help parents improve their skills and education.

Brooks said: “For kids in Kentucky, there are reasons why place, income, and race matter. Those reasons have been imbedded in us for years, and it is going to take time to change policies and attitudes to give every child a chance to thrive. We must learn, grow, and move forward together. It’s going to take all of us. Kids Count brings us the facts. Let’s face the facts and grow together to make Kentucky the best place in America to be young for all children. Our kids deserve no less."

McConnell says Obamacare will have to be replaced gradually

The Patient Protection and Affordable Care Act will be replaced "in a phased-in way over a period of time," not right away, Senate Majority Leader Mitch McConnell said Saturday.

"You can't just snap your fingers and go from where we are today to where we're headed," McConnell told the Kentucky Farm Bureau Federation at its annual meeting in Louisville. "This has to be done carefully."

Sen. Mitch McConnell spoke at the annual Farm Bureau meeting Saturday. (Photo by Ry Barton, WFPL)

"This emerging 'repeal and delay' strategy, which [House] Speaker Paul D. Ryan discussed this week with Vice President-elect Mike Pence, underscores a growing recognition that replacing the health care law will be technically complicated and could be politically explosive," report Robert Pear, Jennifer Steinhauer and Robert Kaplan of The New York Times.

Bruce Schreiner of The Associated Press paraphrases McConnell as saying: "Congress will begin work immediately next year toward repealing President Barack Obama's health-care law but delay the changes as Republicans try to come up with an alternative," something they didn't have to do when they passed repeal bills because they knew Obama would veto them.

McConnell "insisted that some 20 million Americans who have health care through the six-year-old law will not lose coverage, though the likely upheaval in the insurance industry suggests many could," Schreiner reports.

"President-elect Donald Trump says he would like to keep major elements of the law — allowing children to remain on their parents' plans until age 26 and ensuring companies don't deny coverage for pre-existing conditions. But it's unclear how a new version of the law could force insurance companies to provide the latter coverage."

One way to do that would be to keep the law's requirement that all Americans buy health insurance, an idea that many Republicans favored before Obama was elected but opposed when he pushed the law through Congress with only Democratic votes. A possible alternative would be to keep the requirement but allow younger people to buy cheaper policies with thinner coverage.

The details of that will wait, as Republicans push a repeal bill through the House and the Senate, in the latter under budget-reconciliation rules that will prevent Democrats from blocking it with a filibuster. "The health law includes insurance market standards and other policies that do not directly affect the budget, and Senate Republicans would, in many cases, need 60 votes to change such provisions," the Times notes.

The "repeal and delay" approach "is meant to give Mr. Trump’s supporters the repeal of the health law that he repeatedly promised at rallies," the Times reports. "It would also give Republicans time to try to assure consumers and the health industry that they will not instantly upend the health insurance market, and to pressure some Democrats to support a Republican alternative."

Unwinding the law "could be as difficult for Republicans as it was for Democrats to pass it in the first place and could lead Republicans into a dangerous cul-de-sac, where the existing law is in shambles but no replacement can pass the narrowly divided Senate. Democrats would face political pressure in that case as well," the Times reporters write. "It is not sheer coincidence that at least one idea envisions putting the effective date well beyond the midterm congressional elections in 2018."

Tennessee Sen. Lamar Alexander, chair of the Senate health committee, told the Times, “I imagine this will take several years to completely make that sort of transition — to make sure we do no harm, create a good health care system that everyone has access to, and that we repeal the parts of Obamacare that need to be repealed.”

However, the Times reporters write: "Health policy experts suggest 'repeal and delay' would be extremely damaging to a health care system already on edge. “The idea that you can repeal the Affordable Care Act with a two- or three-year transition period and not create market chaos is a total fantasy,” Sabrina Corlette, a professor at the Health Policy Institute of Georgetown University, told the Times. “Insurers need to know the rules of the road in order to develop plans and set premiums.”

The Times reports, "Any legislation is likely to include elements on which Republicans generally agree: tax credits for health insurance; new incentives for health savings accounts; subsidies for state high-risk pools, to help people who could not otherwise obtain insurance; authority for sales of insurance across state lines; and some protection for people with pre-existing conditions who have maintained continuous coverage.

"Republicans said they hoped that the certainty of repeal would increase pressure on Democrats to sign on to some of these ideas. Democratic leaders, for now, feel no such pressure. Republicans 'are going to have an awfully hard time' if they try to repeal the health law without proposing a replacement, said Sen. Chuck Schumer of New York, the next Democratic leader. 'There would be consequences for so many millions of people.'"

New guidelines say sleep aids should only be used short-term; physicians recommends "cognitive behavioral therapy"

Photo illustration: medicalnewstoday.com

Sleep aids are readily available to the one-third of adults who suffer from insomnia, but health-care providers are beginning to steer patients away from them because of the risks the drugs pose, Laura Landro reports for The Wall Street Journal.

“Drugs don’t provide a natural sleep, and the side effects are significant,” Nitin Damle, an internist and president of the American College of Physicians, told Landro.“It’s true in all age groups, but even more problematic for older adults."

After reviewing more than 15 years of evidence, the physicians' group issued new guidelines in May for the management of chronic insomnia, recommending cognitive behavioral therapy as the first-line of treatment for adults. Cognitive behavioral therapy determines patient's actions that may be prohibiting sleep, and then develops a customized list of "do"s and "don’t"s for optimal sleeping.

The guidelines also say that drugs should only be used if therapy is unsuccessful, should only be used short-term, defined as four to five weeks, and only after the benefits and risks have been discussed with the patient. “The intent is for them to be on a short course, and then get off of it,” David Maness, a professor of family medicine at the University of Tennessee Health Science Center in Memphis, told Landro.

“But then the problem is perpetuated, and before you know it, it’s 10 years later, and it keeps getting refilled and no one has reviewed it.” In addition to their addictive properties, prescription sleep aids can cause fuzzy thinking, short-term memory loss, and diminished liver and kidney function, which can cause fatigue, weakness and impaired balance, in older patients. Longer term, sleep drugs may contribute to more serious mental-function issues, Landro reports.

Benzodiazepines, like Halcion, and non-benzodiazapenes, like Ambien, Lunesta and Sonata, are the most commonly prescribed sleeping pills. These drugs, called sedative hypnotics, slow activity in the brain to bring on sleep.

"The American Geriatrics Society recommends against using benzodiazepines or other sedative hypnotics in older adults as first choice for insomnia because large-scale studies consistently show that the risk or motor-vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking the drugs," Landro writes.

There is a new class of sleeping pills that act differently than sedative hypnotics, but are not physically addictive and don't have withdrawal symptoms after stopping the drug. However, they do have some side-effects like drowsiness the next day, sleepwalking and performing activities while sleeping.

Landro reports that over-the-counter drugs can also be risky because many of them use the antihistamine diphenhydramine, which is a type of drugs known as anticholinergics. "A study last year in JAMA Internal Medicine suggested higher cumulative use of anticholinergics, which can impair memory and attention, is associated with an increased risk for dementia," she writes.

Patients who are dependent on sleeping pills should not stop them abruptly, but should taper off of them, Sean Jeffrey, director of clinical pharmacy services at Hartford Healthcare and a clinical professor at the University of Connecticut School of Pharmacy, told Landro.

The hospital ER you visit may be in your insurance network, but your ER doctor may not be, and that could cost you big money

You go to the emergency room of a hospital, choosing it because it's in the network of your health insurer. But then you get a big bill because the ER doctor who treated you isn't in the network.

"Such 'surprises' have surfaced as a major patient problem, but because of entrenched healthcare interests, a solution is not likely anytime soon," Trudy Lieberman writes in her "Thinking About Health" column for Rural Health News Service.

"Because ER docs are usually assured a steady stream of patients, many believe they don’t need to accept potentially lower fees from insurers in exchange for any new patients they might attract by belonging to a network," Lieberman writes. "That’s not the case for other specialists who may rely on insurer networks for more business. Whatever the reason, emergency-room patients may be stuck with huge bills their insurance company may not cover, or it will pay less than if patients had used in-network doctors."

A Yale University study published in the New England Journal of Medicine "found that out-of-network doctors treated 22 percent of the patients who visited emergency departments," Lieberman reports. "The average bill patients incurred was $623. The highest bill was more than $19,000. . . . Not surprisingly, researchers found out-of-network ER doctors ended up getting paid a lot more than those who were part of a network."

Chuck Bell, programs director for Consumers Union, told Lieberman, “Consumers would be astonished to see how poor the odds are of getting an in-network doctor in the emergency room. . . . The fact this type of price gouging has become routine operating procedure in so many emergency departments is shameful and appalling.”

A Texas study by the liberal Center for Public Policy Priorities found that 45 percent of in-network hospitals in the state used by United Healthcare, and 56 percent of Humana Inc.'s hospitals, had no in-network ER doctors.

"The odds of getting redress are also low," Lieberman reports. "Too many consumers don’t contest their bills. Only about 25 percent of those getting surprise bills do, Bell told me. Of those who do protest to their insurer, only half get their bill forgiven or reduced." Medicare patients "can protect themselves from these excess charges should they use a doctor who doesn’t accept Medicare’s fee schedule by buying Medigap policies Plan F and Plan G. For those with Medicare Advantage plans, there’s no protection until the beneficiary reaches the plan’s out-of-pocket spending limit."

"The standard advice, to ask if your doctor is in the network, is silly when it comes to care in the ER. What patient having a heart attack is going to look up and say, 'Hey, Doc, are you with Aetna?' . . . Bell says it will take an act of Congress to solve this problem. Public outrage will have to get much louder if that’s to happen."

Meanwhile, "Think twice before you choose to go to the ER for a problem that can wait until you see your regular doctor," Lieberman advises. "Although Obamacare was supposed to cut down on emergency-room use ... people are still going to ERs for less serious conditions, many being enticed by hospitals themselves that advertise their ER wait times on billboards."

Been faced with surprise billing? Tell Trudy at trudy.lieberman@gmail.com.

UK researchers develop video game to teach agricultural safety to college and high-school students

Screen shot of "Hazard Ridge" video game

Researchers at the University of Kentucky are using a video game to educate young people about the dangers of agriculture, a line of work that has one of the highest rates of workplace fatalities in the U.S., Olivia McCoy reports for UKnow.

Since 2013 researchers at the UK College of Education and the Southeast Center for Agricultural Health and Injury Prevention, in UK's College of Public Health, have been teaching agriculture students and high-school students ag safety using a 3-D game called Hazard Ridge, which "simulates an injury that has occurred in a small rural town where teens are disappearing and the town is going bankrupt," McCoy writes.

"Players serve as the investigator of this issue and learn how agricultural injuries have negative effects on the town’s economy and citizens," McCoy writes. "The game teaches investigative skills and educates on how to conduct a financial analysis of injury."

Jennifer Watson, research coordinator for the Southeast Center for Agricultural Health and Injury Prevention, "said one of the goals for the game is to 'overcome the culture of comfort'," McCoy writes. Watson told McCoy, "Spending their entire lives around dangerous equipment lulls those working and living on farms into a false sense of safety and lessens their belief that they are at risk for injury." She said preventive measures, such as the game, reduces the risk of injury or death. (Read more)

Republicans agree on bill to speed medical research and drug approval, increase funding; some Democrats want changes

Legislation to speed up the federal approval of new drugs and medical devices and to increase funding of medical research passed the U.S. House of Representatives 392-96 on Wednesday, Nov. 30 and is likely to get a Senate vote soon, though it faces opposition from some Democratic senators.

Senate Majority Leader Mitch McConnell

"This medical innovation bill is one that can have a substantial impact for families across the country," said Senate Majority Leader Mitch McConnell, R-Ky., a strong supporter of the legislation. He has pushed for a provision in the bill to allow the U.S. Food and Drug Administration to accelerate approval of stem cell therapies, formally called "regenerative advanced therapies," Sheila Kaplan reports for Stat, the health-and-medicine supplement to The Boston Globe.

The provision "call(s) for devices used with a stem cell product to be considered moderate risk, unless the secretary of Health and Human Services determines that the device or use requires a higher risk classification," Kaplan reports.

Opponents of the provision believe stem-cell therapies should be more closely regulated and subject to clinical trials.

Sen. Elizabeth Warren, D-Mass., in a Monday floor speech, said a big contributor to McConnell's campaign would benefit from this stem-cell therapy provision, Kaplan reports in a separate article. “This mega-donor has poured millions of dollars into Mitch McConnell’s personal campaign coffers and into his Republican super PAC, and now he wants his reward. So the Cures Act offers to sell government favors," she said.

The $6.3 billion legislation would give states $1 billion to fight the opioid crisis; provide $4.8 billion for continuing three "signature Obama administration research programs" over the next 10 years, including: Vice President Joe Biden’s cancer moonshot, the BRAIN Initiative, and the Precision Medicine Initiative; a $500 million increase to the FDA and a number of programs to improve mental health care, Kaplan reports.

A "major sticking point" for the bill, Kaplan reports, is that House Democrats required it to have funding for medical research, but Republicans on the Senate Health, Education, Labor and Pensions Committee would not approve funding without determining where the money would come from.

But now that the Patient Protection and Affordable Care Act is likely to be repealed, with the election of Donald Trump, Democrats have agreed "to underwrite the Cures Act with some money from the ACA, and some to be generated by sales of part of the Strategic Petroleum Reserve," Kaplan writes. NPR adds that it will also be paid for through reduced payments to Medicare and Medicaid.

"Leaders from both parties have called passage of the Cures bill the most important thing Congress could do this year," Kaplan writes.

Opposition to the bill

Warren said she also opposed the Cures Act because she said it had been "hijacked" by the pharmaceutical industry.

The bill has been debated at length over the past three years, Kaplan notes, with "a parade of celebrities" and more than 1,300 lobbyists representing pharmaceutical companies, medical device firms and patient advocacy groups pushing for its passage.

The Society for Public Health Education opposes the bill because it takes money away from the Public Health and Prevention Fund, which pays for programs that address obesity, diabetes, smoking cessation, cancer screenings, access to vaccinations and access to healthy foods, to pay for the Cures Act.

"Taking $100 million from the Prevention & Public Health Fund will have disastrous consequences for the future of public health," the group said.

Many consumer groups continue to oppose the bill, agreeing with Warren, who has said that many Democrats are agreeing to the bill in order to get the additional funds for medical research, which isn't guaranteed and will have to be approved in future legislation.

“While there are positive aspects of this legislation, many provisions would severely weaken the FDA’s drug and medical device approval standards and seriously harm rather than help patients,” Jack Mitchell, director of government relations for the National Center for Health Research, which advocates for patient safety, told Kaplan. “Congress shouldn’t sacrifice the safety and effectiveness of medical products in order to increase research monies.”

Kaplan also reports that many public health advocates have called the bill's provisions a "weaker alternative to the current gold standard of randomized clinical trials."

Sen. Chuck Grassley, R-Iowa, has voiced his opposition to the bill because it "exempts companies from reporting payments made to doctors for receiving continuing medical education sessions, medical journals or textbooks, " Ed Silverman writes for Stat. Consumer groups have also called for the removal of this provision.

Elisia Cohen, UK communication researcher, wins award for work in health promotion, education and communication

Elisia Cohen

Elisia Cohen, professor and Department of Communication chair in the College of Communication and Information at the University of Kentucky, has received a national award for exceptional research in the field of health promotion, health education and health communication.

“I was really honored” to get the Mayhew Derryberry Award, Cohen said in a UK news release. “While there might be other people who produce more scholarly articles or reports, I like to think that my research has a large impact and that my work in communications specifically can extend the reach and effectiveness of health promotion and health communication activities. I think this award was really recognition of that.”

Cohen has worked for 13 years in health-communication research, specifically focusing on cancer prevention and control. She received the award, named for the dedicated public health service officer Mayhew Derryberry, earlier this month at the Public Health Education and Health Promotion awards luncheon in Denver.

Cohen told UKNow that her success in cancer prevention research stems in part from the group efforts of the teams she has worked with. noting that she has collaborated with colleagues in UK's communication department, College of Public Health, College of Nursing and College of Medicine.

“Without those collaborations, really there would be no recognition," she said. "I’ve had the good fortune to work with excellent researchers in health and medicine who are interested in moving the needle on their impact from a communication perspective."

Rep. John Yarmuth named top Democrat on House Budget Committee, which will play a role in Obamacare debate

Rep. John Yarmuth

Rep. John Yarmuth of Louisville has been named ranking minority member on the House Budget Committee, a panel that will consider repeal and replacement of the Patient Protection and Affordable Care Act. Yarmuth has been on the committee for eight years and was elected unanimously to the leadership post by his fellow Democrats.

The committee, which decides on federal spending but doesn’t actually appropriate funds, "will be more relevant in 2017 because Republicans plan to use the budget process to make it easier to pass more controversial legislation affecting spending and taxes," Mary Troyan reports for USA Today and The Courier-Journal.

“Our responsibility will be to make sure the American people understand the relevance of what they’re doing and how it impacts their lives,” Yarmuth told Troyan. “That’s one of the things that has been somewhat a source of frustration of mine these last few years, that the committee seems to be talking to federal employees and Washington media and not really explaining what impact actions and policies might have on American lives.”

The chairman of the committee, Republican Rep. Tom Price of Georgia, is leaving the post to become Secretary for Health and Human Services under President-elect Donald Trump. He had been a leading critic of "Obamacare."

Troyan reports, "While Yarmuth predicts the committee will have largely partisan battles over the Affordable Care Act, tax policy and overall spending levels, he said there may be some common ground over other procedural reforms, such as switching to writing budgets that cover two fiscal years instead of one."

Yarmuth said in a statement, “I believe that budgets are statements of our values, and the Budget Committee provides us the opportunity to show the American people the sharp contrasts between Democratic values and those of Republicans in the House and White House.”

Yarmuth, who is about to start his sixth term, will replace Rep. Chris Van Hollen of Maryland, who was elected to the Senate.

Bevin: Medicaid plan has better chance of approval with Trump

Gov. Matt Bevin

Gov. Matt Bevin said his proposed changes in the Medicaid program have a better chance of getting federal approval because Donald Trump has been elected president.

“Do I think the presidential election will affect that? Oh, you betcha,” Bevin said at a Nov. 29 press conference. “And do I think it will increase the odds of this being approved? I do, and in fact what I think you are going to see is a devolution of responsibility from the federal level down to the state level.”

Another reason the plan may pass under a Trump administration is that Seema Verma, Trump's choice to head up the Centers for Medicare and Medicaid Services, was an advisor to the Bevin administration in constructing the state's new plan, Fortune magazine reports.  To date, proposals in other states with similar provisions as Kentucky's new plan have not been approved.

Bevin said the Medicaid proposal is still under negotiation with federal officials and didn't know if the Obama administration would weigh in on it, though he thought they may approve the part that deals with opioid abuse, Jack Brammer reports for the Lexington Herald-Leader.

This part of the proposal would create a pilot program to increase the number of days Medicaid can pay for inpatient treatment for substance abuse from 15 days to 30 days.

He also said he had talked to Trump and vice-president-elect Mike Pence about the role of states in developing health-care plans, but not about the proposal. Brammer writes, "States are likely to see more block grants from the federal government to decide how health dollars are spent, he said."

Bevin has said Kentucky can't afford to pay for the expansion of Medicaid to those who earn up to 138 percent of the federal poverty line, done in 2014 by former Gov. Steve Beshear, a Democrat, under federal health reform. The expansion has added about 440,000 Kentuckians, most of them working low-paying jobs that don't offer health insurance, to the Medicaid rolls.

The expanded population is paid in full by the federal government through the end of this year. In 2017, the state will be responsible for 5 percent of the cost, rising in annual steps to the reform law's limit of 10 percent in 2020.

Bevin's proposal says it "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 proposal, among other things, would charge monthly premiums, require non-disabled recipients to work, earn a GED or to do community service, and require some of the currently covered benefits, like vision and dental, to be earned through a rewards program. Click here to see the report.

Trump picks Indiana and Kentucky's Medicaid consultant to run Centers for Medicare and Medicaid Services

Seema Verma (Photo: Drew Angerer, Getty)

President-elect Donald Trump says he will nominate the Indiana consultant who advised Kentucky on its Medicaid waiver request to head the Centers for Medicare and Medicaid Services.

Seema Verma also "helped craft Medicaid waiver proposals under the Affordable Care Act in Iowa, Indiana, Ohio, Michigan, and Tennessee," Casey Ross notes for Stat, the health-and-science supplement to The Boston Globe. In Indiana, she "reshaped Medicaid by requiring recipients to pay premiums and tracking their compliance with healthy behaviors."

Kentucky's waiver request seeks two things that officials of the Obama administration have said they would not approve: Requiring beneficiaries with incomes below the poverty level to pay premiums; and requiring those who are not primary caregivers to either work or take job training.

It remains unclear whether officials of CMS and its parent Department for Health and Human Services will act on the waiver request before the Obama administration ends Jan. 20. Gov. Matt Bevin said Trump's election improved the chances of approval for changes that the waiver seeks.

"Verma’s selection to head CMS will quickly change Washington’s posture toward Kentucky’s proposal and many others that seek to rein in spending," Ross writes.

Verma worked for Indiana Gov. Mike Pence, whom Bevin called "my closest political friend" when introducing Pence at a Trump "thank you" rally in Cincinnati Thursday night.

Verma's appointment is subject to confirmation by the Senate.

Officials tout Obama administration's work on substance abuse

By Melissa Patrick
Kentucky Health News

Officials and health advocates touted the Obama administration's work in addressing substance-use disorders at a forum Nov. 29, and also advocated for the passage of the 21st Century Cures Act to increase funding for prevention and treatment services, which continue to be inadequate.

Michael Botticelli

"We have made some significant progress, no more impactful than expanding health care for millions of Americans," Michael Botticelli, director of the Office of National Drug Control Policy, said in the opening remarks of the final "Making Health Care Better" series.

Botticelli noted that the Patient Protection and Affordable Care Act not only requires medical plans to cover mental health and substance-use disorders, but also requires them to be covered in the same way other health conditions are covered, called parity.

"The Department of Health and Human Services estimates the ACA expanded mental health and substance-use disorder benefits and parity protection benefits to more than 60 million people," he said. "Making sure that people have access to treatment for this disease is key to improving the health of our nation."

Botticelli said funding from the 21st Century Cures Act, pending legislation that includes $1 billion to expand access to treatment and prevention services, as well as further provisions for mental-health and substance-abuse parity, would help each this goal. The bill has passed the House and is expected to be called up for a vote in the Senate soon.

"The administration strongly supports this bill," he said. "We hope Congress sends it to the President's desk for his signature so that everyone with an opioid use disorder who wants treatment can get it."

Progress in public health

The deputy undersecretary for Health for Organizational Excellence at the Veterans Health Administration, Dr. Carolyn Clancy, said 50 to 60 percent of veterans suffer from chronic pain. She said the VA has led the way in finding solutions to the opioid epidemic through opioid prescription reductions, online reporting tools, Naloxone programs and telemedicine programs.

Kana Enomoto, principal deputy administrator for the Substance Abuse and Mental Health Services Administration, said 21 million Americans are affected by a substance-use disorder and one out of every seven people will develop one in their lifetime. But only one in ten people who need treatment, get it, she added.

Enomoto praised the ACA provisions that requires substance-use disorder treatment and parity, but added that medication-assisted treatments, like buprenorphine, are not being utilized enough, though research supports the use of them, along with  the "right psycho-social help."

Another successful public health initiative is the new opioid prescribing guidelines for chronic pain released earlier this year by the Centers for Disease Control and Prevention. Dr. Deborah Dowell, senior medical adviser at the CDC, said they are working to inform providers of these changes and said many medical schools and nursing programs have already incorporated them into their curriculum.

The panel noted that future challenges include synthetic opioids, like fentanyl, finding non-addictive medications to treat chronic pain and increasing access to affordable treatment.

Local solutions and advocacy

Don Flattery, chairman of the advocacy committee for the Fed Up Coalition, who lost his 26-year-old son to an opioid addiction, reminded advocates to keep a face connected to this issue, noting that discussions about addiction are often too clinical. "It's absolutely essential to personalize this issue," he said.

Timothy Rabolt, a recovering addict and recovery advocate for college students, said more colleges need "full-fledged collegiate recovery programs" that include recovery housing, recovery spaces that host group meetings and academic advisers who are trained to help these students.

Baltimore Health Commissioner Leana Wen, who has created a successful Naloxone program, said she was pleased the "tone and the discussion really have changed" over the years and that people are now talking about addiction as a disease and a public-health crisis.

"We have to continue to fight stigma with science," she said. "And that's where everyone in this room, all of our advocates, really have to speak up and say that treating addiction as a crime is unscientific. It's inhumane. It's unethical."

Public health and public safety as partners

Cynthia Reilley, director of the Substance Use Prevention and Treatment Initiative at the Pew Charitable Trusts, also pointed out medication-assisted treatments (MATs) are greatly underutilized, but added that they continue to face many access barriers including not enough providers willing to prescribe them, lack of support services for those who are on them and restrictions from insurance policies.

"We know that MAT has been demonstrated to be effective in addressing substance-use disorders. In fact, it is more effective than other intervention in reducing dependence on prescription opioids, heroin and alcohol," she said.

Daniel Raymond, policy director of the Harm Reduction Coalition, talked about the importance of syringe-exchange programs and Naloxone, said, "Several years ago, harm reduction would not be represented in one of these discussions."

Sheriff Peter Koutoujian of Massachusetts said, "We can't incarcerate our way out of addiction."

Koutoujian, who is also a former prosecutor and legislator, touted the success of the substance-use disorder programs offered to every inmate in his jail who needs it, including access to medication-assisted treatment and a "recovery coach" to support them when they leave.

"You shouldn't have to come to jail to get that type of treatment or programming, you should be able to get it on the street beforehand," he said.

Koutoujian said people in addiction programs must have access to a full range of services if we expect long-term recovery, including appropriate housing, mental health care, substance-use disorder supports and strong social network support.

"Until we actually get our leaders to step forward and provide some of those services, we are just going to keep having the same conversation over and over again," he said.

What's next?

Tom Vilsack

Agriculture Secretary Tom Vilsack, closing the forum, said the U.S. has responded with "great vigor" to diseases like diabetes and cancer, each of which affects a similar number of people as substance-use disorders, "but here we are with 21 million of our fellow citizens suffering from substance-use disorders and only one in 10 of them have access to treatment."

He highlighted many of the Obama administration efforts in fighting the opioid epidemic, but placed special emphasis on the role of communities in the fight, especially in rural communities, which often don't have adequate resources to help those with addictions.

Vilsack said his mother had been an alcoholic and that it took many years before she was able to successfully become sober, but only because she had access to long-term recovery and the support systems within their community, including Alcoholics Anonymous and her sponsors and a supportive family.

"In the past, we have suggested that perhaps if these folks had a little more character, if they had a little more will power, if they had a little more faith -- then they would be able to overcome their addiction, just by shear will," Vilsack said. " This is a disease and it needs to be understood by everyone that it is a disease."

Vilsack called on advocates to push for more prevention, to push for more treatment, to create communities of support and to find creative ways to deal with the issues of housing and economic opportunities.

"Use your voice everywhere -- at the local level, at the state level, at the federal level, everywhere -- use your voice to explain to people who can make a difference in the lives of these 21 million Americans," he said.

Vilsack ended the event with a passionate call to continue the fight: "I would hope that we are a strong enough, compassionate enough, intelligent enough country to understand the importance of taking this on and taking it head on," he said. "People, we can change this. We can be the country that we should be, but it's going to take everybody here and thousands more like you."

Study finds Kentuckians on Medicaid expansion make heavy use of preventive screenings

Kentuckians covered by Medicaid through its expansion in 2014 are using their preventive screening benefits more than the traditional Medicaid population, according to a report done for the Foundation for a Healthy Kentucky.

"One of the benefits of getting more people insured is that they take advantage of the preventive services that can lead to improved health and lower health care costs in the long run," Ben Chandler, president and CEO of the foundation, said in a news release. "That positive trend is what we're seeing in Kentucky in terms of breast and colorectal cancer screenings, preventive dental services and diabetes and hepatitis C screenings for Kentuckians with low incomes."

These findings come as no surprise, since those who qualify for Medicaid under the expansion (to those who earn up to 138 percent of the federal poverty line) often work at low-paying jobs that don't provide health insurance, are students or are caretakers and have gone without health insurance for a long time.

Since the implementation of the Patient Protection and Affordable Care Act and the state's expansion of Medicaid, Kentucky's uninsured rate has dropped by more than half, from 14.3 percent in 2013 to 6 percent in 2015 respectively, according to the report.

One of the 10 essential benefits of the reform law is free preventive health care, a benefit that thousands of Kentuckians have taken advantage of.

The study found that in the second quarter of 2016, Medicaid paid for 9,848 breast cancer screenings, with 87 percent of them (8,500) for Kentuckians covered by the expansion. The other 1,251 screenings were for patients who qualified under traditional Medicaid.

This was similar to the same time frame last year, when 88 percent of the 10,191 breast screenings were for those covered by the expansion.

"Screenings for breast cancer among those living on lower incomes can be particularly important because, statistically, low-income women have a higher risk of not being diagnosed until the later stages of breast cancer," Chandler said. "If doctors can catch the cancer early with regular mammograms so patients can get treatment at the earlier stages, we're talking about saving lives while also reducing long-term costs."

MEDICAID DATA BY QUARTER, January 2015 through June 2016

Foundation for a Healthy Kentucky graphic on Medicaid preventive services in Kentucky

This trend of increased screenings by the expansion population also held true for other screenings during the second quarter: 88 percent of the 6,289 colorectal cancer screenings; 79 percent of the 4,589 diabetes screenings; and 65 percent of the 5,820 hepatitis C screenings.

The report also found that Medicaid covered 43,463 preventive dental screenings between April and June and that 76 percent, or 32,968, were for expansion patients.

"In my experience, Medicaid expansion patients first used their plans at the dentist to address dental neglect in hopes of eliminating pain and getting prepared for the workforce. It is very difficult to concentrate in school or at work with a toothache," Laura Hancock Jones, chair of the Kentucky Oral Health Coalition and a member of the foundation's Community Advisory Committee, said in the release.

Medicaid has also seen a big jump in substance-abuse treatment, from 5,675 services during the first quarter of 2015 to 15,234 during the second quarter of 2016, says the report. More than 56,600 substance-abuse treatment services have been covered by Medicaid in those 18 months.

Mental-health benefits and the treatment of substance-abuse disorders are also benefits required under federal health reform.

"Substance abuse is one of the most critical health and safety issues facing Kentuckians," Chandler said. "Overdose deaths continue to climb, and addiction exacts a terrible emotional, financial and physical toll on families."

Medicaid also covered 6,620 births, 1,769 of which were delivered by expansion patients, during the second quarter of this year.

The report 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 Patient Protection and Affordable Care Act over three years.

Kentucky's health rankings are poor in just about every category,  with some of the highest rates of cancer, diabetes, obesity, stroke and heart disease in the nation. Health advocates look for improvements in these rankings to come from long-term preventive care, which many now have because of health reform and the expansion.

But health advocates and many Kentuckians on Medicaid are concerned about what will happen to these benefits if the state's Medicaid program is changed, as Gov. Matt Bevin has proposed, or health reform is repealed, as President-elect Donald Trump has promised.

Bevin says the state can't afford to have nearly one-third of its population on Medicaid and has submitted a proposal to the federal government to let the state require beneficiaries to pay monthly premiums and require non-disabled recipients to work or to do community service. It also requires some of the currently covered benefits, like vision and dental, to be earned through a rewards program. The plan is currently under negotiation with federal officials.

The expanded population is paid in full by the federal government through the end of this year. In 2017, the state will be responsible for 5 percent of the cost, rising in annual steps to the reform law's limit of 10 percent in 2020. Bevin's 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.

President-elect Donald Trump and the GOP-controlled Congress have promised to repeal health reform, though Trump has said insurance companies should still have to cover pre-existing conditions. Republicans in Congress have long wanted to turn Medicaid into a block-grant program, largely run by the states.