Ky. and most surrounding states had fewer companies on government health-insurance exchanges this year than last year

The number of health insurance companies offering subsidized coverage didn't shrink just in Kentucky, but in most of adjoining states, according to a study done for the Foundation for a Healthy Kentucky.

The report found that the number of insurers on Kentucky's exchange dropped to three in 2017 from seven in 2016. Likewise, the number of insurers in Illinois and Indiana also dropped by four. Ohio's exchange lost five insurers during this time frame, but it still has 11 to choose from. Virginia, with 11, and West Virginia, with 2, remained the same.

The report found that while Kentucky continues to have three insurers on the exchange, only one of them covers all 120 counties, leaving 59 counties with one carrier, 52 counties with two carriers and only nine counties with all three.

"One of the concerns about the uncertainty surrounding the Affordable Care Act is that the number of insurers offering plans is dwindling in many markets, and that's exactly what happened in Kentucky," Ben Chandler, president and CEO of the foundation, said in the news release. "Kentuckians living in more than 90 percent of counties in the commonwealth had just one or two carrier choices; half of Kentucky counties had only one carrier option. And the choices were most limited in the lower-income, less-healthy areas of the commonwealth."

The ACA requires everyone to be covered by health insurance, either public or private, or pay a penalty. Consumers who buy plans on the exchange, depending on their income, may be eligible for tax credits to reduce their monthly premium payment amounts.

The report also found that in 2017, the second-lowest priced silver-level plan for a family of four with an income of $60,000 was lower in Kentucky than both the U.S average and five of its eight neighboring states, though the monthly premium cost for all of the states in the study was about the same, around $405, after the varying amount of tax credits was subtracted from the varying premium costs.

For example, Kentucky's premium for this plan is $939, and the tax credit is $534, leaving the person to pay $405 each month. The U.S. average premium for this plan is $1,090, with a tax credit of $686, leaving the person to pay $404 each month.

Chandler said that fewer carriers lead to higher premiums, less competition, and higher cost to taxpayers who pay for the tax credits to buy those premiums down.

He also pondered what would happen if insurers refused to cover some areas of the state altogether, thus removing any opportunity for a tax credit for those residents and making it more expensive for them.

"That would move Kentucky backward by once again increasing the number of people who cannot afford insurance, so they rely on the emergency room or just delay or skip essential health care," he said.

The study was done by the State Health Assistance and Data Center at the University of Minnesota.

State health officials urge spring-break travelers to use caution against the Zika virus

State officials are warning spring-break travelers to take precautions against the Zika virus if they are traveling to areas where the virus has been identified. Specifically, they are encouraging travelers to take steps to prevent mosquito bites, advising against unprotected sex and warning pregnant women to not travel to these areas

“This is the time of year that universities, school districts and other organizations observe spring break and many Kentuckians will be traveling for vacation or mission and service trips,” Health Commissioner Hiram Polk said in the news release. “If that is the case, we urge you to research the area in which you’ll be traveling. If Zika has been documented in the area, make sure you take appropriate steps to prevent mosquito bites.”

Detailed information about Zika infected areas can be found on  the Centers for Disease Control and Prevention’s Travelers’ Health Website http://wwwnc.cdc.gov/travel/

Advice to avoid the Zika virus when travelling:

• Wear long-sleeved shirts and long pants. In warmer weather, wear lightweight, loose-fitting clothing that covers exposed skin. Wear socks that cover the ankles and lower legs. 
• Use  EPA-approved repellents such as DEET, picaridin, IR3535, oil of lemon eucalyptus or para-menthane-diol, or 2-undecanone. Reapply as directed.
• Apply sunscreen before insect repellent if using both. 
• Do not use insect repellents on babies under two months of age. Instead, dress your baby in clothing that covers the arms and legs, or cover crib, stroller, or carrier with mosquito netting.
• Treat clothing and gear with permethrin. Do not use permethrin directly on your skin. 
• Pregnant women should postpone travel to areas with Zika virus transmission. 

Also, if you are planning to get pregnant and are traveling to a Zika virus-affected location, you should talk to your provider before going to discuss the risk and options available, the release says.  

To keep travelers from spreading the virus when they return home, the health department reminds travelers to wear mosquito repellent for three weeks after returning, so as not to infect other mosquitoes that could bite others and to wear condoms during any sexual activity to prevent any sexual transmission of the virus.

The CDC recommends women should use condoms for at least eight weeks and men for at least six months after potential exposure, noting that those who are pregnant should use condoms throughout the pregnancy.

Increasing scientific evidence suggests a link between infection in pregnant women and infants born with birth defects such as microcephaly, a condition where the head is smaller than normal and is likely to be associated with significant nervous-system abnormalities and life-long complications.

Symptoms of the virus include fever, rash, joint pain, red inflamed eyes, or other acute symptoms, though many who are infected never show symptoms. Travelers with these symptoms should consult with their medical provider within two weeks of returning to the state. Currently there is no vaccine to prevent Zika infection.

Kentucky has had 35 confirmed cases of Zika virus, all of which involved contracting the illness while traveling to Zika-infected areas.

For further information or to sign up for health alerts visit http://healthalerts.ky.gov/zika or the CDC website at www.cdc.gov/zika. To get the CDC Zika text updates, text PLAN to 855-255-5606.  In Kentucky, follow KYHealthAlerts on Twitter or @martymosquito on Instagram.

Nurse practitioners ease doctor shortage, but will have to wait to get more authority to prescribe narcotics; opioid epidemic cited

Nurse practitioner Robin Szczapinski talks with her patient, 

Harold Brashear Sr., at the Louisville Veterans Affairs Medical

Center. (Courier-Journal photo by Maggie Huber)

They're not doctors, but they do a lot of the same things, probably most things most patients need. They're nurse practitioners, officially known as advanced practice registered nurses, or APRNs. Kentucky has 5,400 of them, and they are helping ease the state's shortage of doctors, reports Darla Carter of The Courier-Journal.

“Since the expansion of the Affordable Care Act, there’s been an increased need for primary care providers and there’s just not enough physicians within the state of Kentucky,” Lewis Perkins, a geriatric nurse practitioner and chief nursing officer at Louisville's Norton Hospital, told Carter.

Nurse practitioners in Kentucky must have a collaborative agreement with a physician to prescribe narcotics and some other controlled substances, and for the first four years of prescribing, other drugs. They would like those restrictions removed, and a bill in the legislature would do that.

The sponsor of Senate Bill 158, Sen. Paul Hornback, R-Shelbyville, told Carter he introduced the bill only to get discussion started. It did, at least for people whom Carter contacted.

Dr. William C. Thornbury, president of the Kentucky Academy of Family Physicians, sent Carter a statement saying the bill "conflicts with our governor's policy to combat opioid abuse. Removing the collaborative agreement between a physician and an APRN eliminates the consultation process, which is an important protection in place that helps curb the abuse that is ravaging our commonwealth.” The Kentucky Medical Association also opposes the bill, citing similar reasons.

Wendy Fletcher, a "doctorally-trained nurse practitioner" and president of the Kentucky Coalition of Nurse Practitioners & Nurse Midwives, "noted that nurse practitioners are monitored through the U.S. Drug Enforcement Administration and the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system – just as physicians are – and are held to a high standard by the Kentucky Board of Nursing," Carter reports.

Republican health-law drafts would reduce federal support for Medicaid and subsidies of private insurance

Kentucky would have to keep paying more for Medicaid, and people with federally subsidized health insurance would get less support, under a committee draft of a bill to repeal and replace the Patient Protection and Affordable Care Act.

"States that grew their Medicaid programs under the health law could maintain their expanded programs until 2020 before federal funding would decrease," The Wall Street Journal reports on the draft by the House Energy and Commerce Committee.

Then-Gov. Steve Beshear expanded Medicaid in 2014, adding 440,000 Kentuckians with incomes up to 138 percent of the federal poverty line. The state is paying 5 percent of this year's cost, and current law calls for that to increase in annual steps to 10 percent in 2020.

The House committee draft would shrink the federal share and require states to pay more, starting in 2020. The federal government pays about 70 percent of traditional Medicaid costs in Kentucky.

"Starting on Jan. 1, 2020, the federal government would begin to reimburse states at a lower rate as they transition to a system in which states would get a set amount of funding, tied to the size of their Medicaid population, along with more flexibility on how they could spend it," the Journal reports.

"The proposal is aimed at appealing to centrist Republicans who haven’t wanted to see the most generous federal funding for the program abruptly withdrawn, which could cause states to shrink Medicaid rolls. Some conservative Republicans have pressed for a more immediate rollback of the program."

Rep. Brett Guthrie

Among those are 2nd District Rep. Brett Guthrie, R-Bowling Green, who said of 2020, “Some people thought that was too far in the distance.”

Conservatives are focused on reducing the cost of the program. Under the committee draft, federal Medicaid spending would increase with the "chained" consumer price index, plus 1 percentage point. "The chained CPI usually shows slower inflation than the index used currently," the Journal notes. "Critics worry, however, that using chained CPI, which will reflect growth slower than the rise in health-care costs, would cause the government’s funding to fall short of needs."

The biggest obstacle to a new Medicaid program may be differences between states that expanded it and those that did not. The Journal notes that Republicans from the latter states "have balked at the idea of a plan that would reward states that did," many controlled by Republicans.

Kentucky is in an unusual position because its program was expanded by a Democratic governor without the involvement of the legislature, where Senate Republicans could have blocked it, but now the state is fully controlled by Republicans.

In his primary campaign, Gov. Matt Bevin said he would abolish the expansion, but after being nominated said he would scale it back, following an Indiana model that charges small, income-based premiums and imposes certain work requirements. His request to do that is pending before federal officials, one of whom helped draft the Indiana plan.

The broader political problem for Republicans is described by William Galston of the Brookings Institution: "The states that Donald Trump carried in 2016 disproportionately benefitted from the expansion of Medicaid that was one of the building-blocks of Obamacare, and they will suffer disproportionately from Medicaid cuts. Between 2013 and 2016, Gallup finds, the three states with the largest percentage-point reductions in their populations without health-care coverage were Kentucky, Arkansas, and West Virginia." All expanded Medicaid.

Private, subsidized insurance

In addition to Medicaid expansion, the ACA provided subsidies for private insurance bought on government exchanges: tax credits for people with incomes up to four times the poverty level, and cost-sharing for those up to 250 percent of the poverty line, to provide lower deductibles and copays on plans that cover a larger share of expenses.

For a larger version of either chart, click on the image

Under GOP replacement plans that have been publicly discussed, the subsidies would be at least a third less than now offered, and would rise more slowly over time, says the Kaiser Family Foundation.

"People who are lower income, older, or live in high premium areas would be particularly disadvantaged," Kaiser reports on its analysis.

Under a discussion draft circulated by House leaders, "The average tax credit for current ACA marketplace enrollees would rise from an estimated $2,957 in 2020 to $3,729 in 2027. By comparison, the average tax credit under the ACA would be $4,615 in 2020, increasing to $6,648 in 2027," Kaiser reports.

The three major Republican proposals' tax credits "vary with age but not income and grow annually with inflation," Kaiser notes. Current tax credits "vary with family income and the cost of insurance where people live, as well as age, and grow annually if premiums increase. These various tax credit approaches can have quite different implications for different groups of individual market purchasers.  For example, the tax credits under the ACA are higher for people with lower incomes than for people with higher incomes."

Republican proposals would also provide tax credits to people who don't now get them. Some Republicans have said no subsidies should go to people above a certain income level.

UK plans to develop its third regional medical school in Northern Kentucky; others are to be in Bowling Green and Morehead

The University of Kentucky College of Medicine plans to develop its third regional medical school in Northern Kentucky, in an effort to increase the overall number of physicians in the state. The other two are in Bowling Green and Morehead.

"In Kentucky we have a shortage of physicians, especially primary-care physicians, throughout the state,” UK President Eli Capilouto said in a news release. "We are working in close partnership with leading universities in our state and regional medical centers to directly respond to this need. Additionally, this collaboration will allow us to expand college of medicine enrollment in a manner that effectively and efficiently utilizes existing resources throughout the state."

The Bowling Green program is supposed to begin enrolling students in 2018, and the Morehead program sometime thereafter. The Northern Kentucky initiative will be in partnership with Northern Kentucky University and St. Elizabeth Healthcare.

Dr. Robert DiPaola, dean of the UK medical school, said it is at capacity and can't expand enrollment without the help of regional partners. Currently, the College of Medicine enrolls 547 students, including 139 recently admitted into the class of 2020.

Details of the broad-based initiative are still being ironed out, though UK officials have signed a memorandum of understanding with the partners. The four-year Northern Kentucky program will utilize the same curriculum and assessments as UK's Lexington campus.

The release says the "on-site faculty will have UK College of Medicine appointments and teach in small groups and provide simulation/standardized patient experiences with lectures delivered on-site from Lexington utilizing educational technology. Additionally, clinical experiences will occur at St. Elizabeth Healthcare and surrounding community practices."

Federal study in Central Appalachia will try to see if living near a surface coal mine is bad for your health

Scientists from the National Academies of Sciences, Engineering and Medicine will study Eastern Kentucky, West Virginia and the coal regions of Virginia and Tennessee to determine if living near a surface mine increases the risk of health problems, Bill Estep reports for the Lexington Herald-Leader.

"A number of studies have shown that mountaintop mining is associated with higher rates of cancer, heart disease and other health problems in Central Appalachia," Estep writes. "Michael S. Hendryx, a professor who did several of the studies while formerly at West Virginia University, told the Herald-Leader last year that the studies were adjusted to account for factors such as higher rates of smoking and obesity in the region."

"However, the coal industry has fiercely disputed the studies, and a 2012 industry-funded study by a Yale University researcher and others concluded that 'coal mining is not per se the cause of increased mortality in rural Appalachia,'' Estep writes. "The study by the National Academies could identify gaps in existing research and help settle some of the uncertainties about the issue."

The U.S. Office of Surface Mining Reclamation and Enforcement, which commissioned the two-year study, "said the research agency would choose experts to examine a 'growing amount of academic research that relates to possible correlations between increased health risks as a result of living near surface coal mine operations,'" Estep writes. "The study will involve synthesizing existing research, not conducting new field studies." (Read more)

KentuckyOne Health parent firm's debt rating downgraded again; explores merger that would create largest not-for-profit chain

Flaget Memorial Hospital at Bardstown is part of the chain.

S&P Global Ratings has cut its debt rating for Catholic Health Initiatives, a nonprofit with KentuckyOne Health hospitals in Louisville, Lexington, Bardstown, Berea, Campbellsville, London, Martin, Mount Sterling, Nicholasville and Shelbyville.

S&P, former Standard & Poor's, dropped CHI's rating from A-minus to BBB-plus Thursday. That is just two spots above a junk-bond rating. However, the BBB-plus rating was upgraded from negative outlook to stable outlook, meaning no further downgrades were looming, Dave Barkholz reports for Modern Healthcare. Fitch Ratings also downgraded the company's debt rating in July from A-plus to BBB-plus, he notes.

"While management's current turnaround plan has created an expectation for stabilization and modest improvement over the next 18 months, it is our opinion that it will take several years on the current financial improvement trajectory for CHI to return to a higher rating," S&P credit analyst Martin Arrick said in the downgrade report.

CHI said in a statement that it has "considerable strengths," including $16 billion in annual revenue, 103 hospitals across 22 states and a solid balance sheet, with assets of $22.7 billion. "We expect a strengthening of our financial performance – and a strengthening of our credit profile," CHI said.

Barkholz reports, "The system's turnaround plan is now being shepherded by interim operating chief Anthony Jones, a Los Angeles-based management consultant who replaced longtime COO Michael Rowan, who resigned in December."

CHI's debt is relatively high for a system of its size, Barkholz notes. The company's annual debt service, interest paid on its bonds and borrowing, is about $460 million on total debt of $9 billion, according to Barkholz.

CHI, which is in affiliation talks with Dignity Health, told Barkholz that its turnaround plan is gaining traction as evidenced by improved earnings in its second quarter, which ended Dec. 31.

Its "alignment" discussions with Dignity continue, even as it works its turnaround plan, Barkholz reports. A merger between the two companies would create the nation's largest not-for-profit hospital chain, with 142 hospitals combined and an annual revenue of more than $26 billion.

Dignity's overall debt is lower: $5.25 billion, he writes. However, it, too, has maximum debt service to carry: $408 million annually. The two companies are expected to decide whether to merge sometime this year.

House health-care draft suggests a plan that could leave rural areas short of coverage

A 100-page draft of a House Republican plan to repeal the Patient Protection and Affordable Care Act suggests that rural, middle-class Americans may soon struggle to afford health insurance.

The document, which was leaked to Politico last week, specifies that Medicaid expansion for low-income, able-bodied adults won’t be completely eliminated, but eligibility and funding will be rolled back after 2020, Vann R. Newkirk II reports for The Atlantic.

"The draft also contains a provision changing federal funding for Medicaid in 2020 onward from an open-ended obligation to a system where the per-person spending every year is capped based on spending levels in 2019 and increased annually to correspond with medical inflation," he writes.

Then-Gov. Steve Beshear expanded Medicaid under the law, to people with household income up to 138 percent of the federal poverty level, now $16,394 for an individual or $33,534 for a family of four. Now the state is having to pay 5 to 10 percent of the cost, and Gov. Matt Bevin says the state can't afford it. He has asked for permission to change the program, but what Congress does with the program nationally would likely override action in Kentucky.

Rural residents, who rely more heavily on public insurance than do city-dwellers, are particularly vulnerable to Medicaid cuts. The health issues that are prevalent in rural areas are serious and contribute greatly to the climbing mortality among middle and lower class white Americans, he notes. "People like coal miners in Trump country in Kentucky and West Virginia are on the frontiers of several developing health crises, and per-capita spending caps on Medicaid would only further limit their states’ ability to respond," Newkirk writes.

The draft plan by House Republicans repeals the tax-based individual mandate to have health insurance and replaces it with an incentive to maintain continuous coverage. This proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months and who purchase insurance on individual, small group, or exchange markets, Newkirk says. The fee would also apply to young adults who don't enroll in coverage as soon as they age out of their parents' plans. In addition, the added surcharge would be paid as profits to insurers rather than being remitted as taxes to sustain the system, he writes.

Another reform set forth in the draft is a measure to replace the cost-sharing reductions and premium tax credit subsidies of the ACA's exchanges with a refundable tax credit. The existing tax credit is adjusted by income, age, and the average price of insurance in a person's market. The draft version of the tax credit would only take into account age, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60, Newkirk notes.

While older people who are likely to have more health problems would get more subsidy than "young invincibles," Newkirk writes, the worry is that adequate medical care will be out of reach for lower-income people who are also more likely to have health problems. Geographical factors are also likely to become an issue for a tax credit based solely on age, since medical costs vary substantially from place to place.

A tax-credit plan that doesn’t account for the actual cost of a person’s health insurance might reasonably be expected to create areas where coverage is simply unaffordable, Newkirk notes. Research suggests that health-insurance premiums are higher for rural counties and states.

Newkirk writes, "Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers. . . . The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states’ ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them," Newkirk writes.

Newkirk says that disparity between costs and access for rural Americans creates a conundrum for Republicans. "By reducing state Medicaid financial flexibility, reducing oversight over minimum insurance requirements, instilling continuous coverage requirements, and removing regional costs offsets, their Obamacare replacement would in essence put health insurance even further out of reach for sicker, rural patients who need it more and then penalize them for being left out," he writes.

Many rural Americans already suffer the effects of “health care deserts” because of collapsing rural hospital systems and waning access to basic specialty services. In addition to those health care and service deserts in rural areas, Newkirk writes, Republicans would be contributing to newfound “coverage deserts.”

Senate medical-review panel bill passes out House with changes after two hours of debate; Senate says OK, sends it to Bevin

This story has been updated to reflect concurrence of the Senate on March 3.

By Melissa Patrick
Kentucky Health News

A Senate bill that would establish review panels for lawsuits against health-care providers passed narrowly out of the state House with changes that are meant to make it more constitutional. The Senate concurred with the House's changes to the bill on March 3 and the bill now heads to the governor's desk for his signature.

The review panel would be made up of three physicians that would determine if lawsuits against health-care providers have merit before being filed in court. All parties would have to agree to bypass the review panel in order to take the case directly to court.

After almost two hours of debate, Senate Bill 4, sponsored by Sen. Ralph Alvarado, R-Winchester, passed 51-45, with 11 Republicans joining 34 Democrats in voting against the measure.

Rep. Robert Benvenuti, R-Lexington, presented the bill on the House floor and said review panels create a "fair, balanced process." He said Kentucky needs liability reform because providers are "fleeing the state" and paying much higher premiums than their counterparts in other states that have some type of reform, which he said ultimately leads to access issues for everyone.

"We've created a litigation industry in this commonwealth," he said.

Rep. Chad McCoy, one of three Republicans who spoke against the measure, said that such panels have proven ineffective in other states. He noted that 27 states have adopted review panels since the 1970s, but 10 of those states have since gotten rid of them because "they don't work."

McCoy, a lawyer from Bardstown, told House members that review panels are unconstitutional and that they "walk all over" a person's right to a trial by jury. He pointed out that they also create more claims because plaintiffs' attorneys often view them as an inexpensive way to "run it up the flagpole" to see if a case is worth pursuing.

"We're getting ready to create a new government agency and more red tape," he said. "I'm a Republican. I don't like that."

McCoy suggested that instead of review panels, the state needs to pursue a more successful system called "affidavit of merit," which would require claims to be reviewed for their merit before they are even allowed to go to court. Alvarado, after the bill's committee meeting Feb. 28, said he would support the idea, but that to be successful it would also require a constitutional change to allow economic caps on settlements. Only voters can change the state constitution.

Representatives Jason Petrie of Elkton and Kenny Imes of Murray were the other two Republicans who spoke against the bill.

Rep. James Kay, D-Versailles, spoke against it, saying it would create barriers to the courts: "This bill closes our courts, placing a barrier of doctors between the citizens of Kentucky and the judge and the jury -- closing the courthouse doors."

Rep. Jason Nemes, R-Louisville, who helped draft the House changes in the bill, said he could never have voted for the bill without the changes, which he said made it more constitutional.

Nemes explained that the House changes did three things: It sets a firm nine-month time frame for the opinion to be issued, instead of the loose, extendable six months allowed by the original bill; it calls for a list of volunteer lawyers and physicians to fill the panel seats, instead of these positions being appointed; and "most importantly," it would allows the trial judge to determine if the panel's opinion is admissible in court, instead of being automatically admitted.

Similar legislation has been introduced for years and was passed out of the Republican led Senate, but never heard in the Democrat led House. Alvarado, a physician, has been the bill's sponsor for three years.

Rep. Tom Burch, D-Louisville, former chairman of the House Health and Welfare Committee, said he had successfully killed this bill in the past because it is not constitutional. He said, "It does not help the patients. It only helps the providers."

While Alvarado has long called this bill his "white whale" -- and it looks like he's finally about to harpoon it -- he said in an interview that it's final passage wouldn't mean he is finished with his quest for tort reform in Kentucky. He said: "There's more coming. You know me."

Alvarado is also sponsoring another bill, Senate Bill 18, that would prevent medical peer reviews from being used as evidence in malpractice cases. It passed out of the House Judiciary Committee March 1.

House sends Senate bill to limit most potent painkiller prescriptions to three days, target traffickers of fentanyl

The state House has sent to the Senate a bill to put a three-day limit on prescriptions of high-potency painkillers, and increase penalties for the sale of fentanyl, in an effort to stem the state's opioid epidemic.

House Bill 333 would impose the three-day rule on Schedule II controlled substances, such as OxyContin. "It includes exceptions meant to protect medical professionals' ability to prescribe a larger supply if they deem it medically necessary and exempts patients with chronic or cancer-related pain from the new limit," reports Morgan Watkins of The Courier-Journal. "Patients getting treated in a hospital or who need pain medication after a major surgery or significant trauma would be exempt from the proposed restrictions too."

The bill would raise the penalty for selling any amount of fentanyl, a powerful synthetic opioid that is often sold surreptitiously. It would eliminate the current lighter penalties for trafficking less than 2 grams of the drug and would create a new offense of trafficking in a misrepresented controlled substance, punishable by one to five years in prison.

The bill passed the House 95-1 on Feb. 28. Rep. Lynn Bechler, R-Marion, cast the only opposing vote. The bill's prime sponsor is freshman Rep. Kimbely Poore Moser of Taylor Mill.

Rep. John Blanton, R-Salyersville, told the House, "We have to take those measures that protect our young people." However, the Kentucky Rural Health Association said the bill could lead to under-treatment of pain: "While the intention is admirable, legislating medical treatment is a slippery slope," it said in a statement.

Beshear, Republicans debate the record of Obamacare in Ky.

Kentucky's roles in implementing and changing federal health-care law were on national display Tuesday night, as former Gov. Steve Beshear gave the televised Democratic response to President Trump's first address to Congress and Kentucky Republicans criticized Beshear's embrace of "Obamacare."

Trump set the table in his speech, using Kentucky as an example of why the Patient Protection and Affordable Care Act should be repealed and replaced: "Governor Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing." Trump has yet to endorse a replacement plan, but he said five principles should guide Congress:

• Americans with pre-existing conditions should "have access to coverage." Republicans talk about doing that through insurance pools for higher-risk people, which require government subsidies to work. Critics say many people still couldn't afford insurance from high-risk pools, which Kentucky once had.
• Regular coverage should be subsidized through tax credits and expanded use of health savings accounts, which are exempt from taxes, and people must get "the plan they want, not the plan forced on them by the government." The ACA set minimum requirements for coverage, making it more expensive, especially for people who had bought low-cost policies.
• "We should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out." Republicans talk about giving states block grants for Medicaid, with few strings attached but limiting federal funding of the program. There is debate about how to equitably fund states that expanded Medicaid under the ACA and those that didn't.
• "We should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance. and work to bring down the artificially high price of drugs and bring them down immediately."
• "The time has come to give Americans the freedom to purchase health insurance across state lines, creating a truly competitive national marketplace that will bring cost way down and provide far better care."

Beshear, speaking from the downtown Lexington Diner, said "So far, every Republican idea to replace the Affordable Care Act would reduce the number of Americans covered, despite your promises to the contrary."

Trump said in January that he wanted "insurance for everybody," and presidential adviser Kellyanne Conway promised that no one would lose their insurance. "However, an analysis of the current Republican plan to replace the health-care law shows that millions who have coverage today would lose it," NPR health correspondent Alison Kodjak reported, citing a presentation made to the National Governors Association last weekend.

Beshear continued, "Mister President, folks here in in Kentucky expect you to keep your word, because this isn't a game, it’s life and death for people. These ideas promise access to care, but deny the importance of making care affordable and effective. They would charge families more for fewer benefits and put the insurance companies back in control."

Kodjak says the Republican approach "could help reduce premiums for those who would like to buy a more stripped-down insurance policy," but the draft plan of House Republicans is "likely less generous, so people could pay more for health care even if they have lower premiums."

Beshear accused Republicans of thinking "that folks at the lower end of the economic ladder just don't deserve health care. That it is somehow their fault that their employer doesn't offer insurance or that they can't afford to buy expensive health plans." He added later, "Before the Affordable Care Act, they woke up every morning and went to work, just hoping and praying they wouldn't get sick because they knew that they were just one bad diagnosis away from bankruptcy."

When he was governor, Beshear expanded Medicaid to people earning up to 138 percent of the federal poverty level, now $16,394 for an individual or $33,534 for a family of four. As a result, the share of Kentuckians without health insurance dropped to 6 percent from 14 percent, the largest reduction of any state.

Bevin says the state can't afford to pay its 5 to 10 percent share of the expansion cost, and has asked federal officials to waive rules and let the state charge Medicaid enrollees small, income-based premiums and require able-bodied adults who are not primary caregivers to work or perform work-related activities. The Trump administration is expected to approve the waiver.

Speaking to reporters in Washington Monday, Bevin said of Beshear, "Because he unilaterally chose to expand Medicaid in Kentucky, enrolled hundreds of thousands of people, the net result of it has been a remarkable decline in access to health-care coverage: more people covered, but covered by what? Fewer people able actually to even see a doctor." Then he immediately started talking about private insurance, noting that half of Kentucky's counties have only one Obamacare provider. "There are only three now in the entire state, only one that covers the entire state."

Asked how the expansion could have reduced access to coverage when it added 440,000 Kentuckians to Medicaid, Bevin communications director Amanda Stamper said in an email that the governor was "referring to more than simply Medicaid expansion," and "the loss of quality health care coverage and shrinking networks. Medicaid coverage is not quality health coverage. Network adequacy is an issue, as fewer and fewer doctors want to deal with [the] administrative burden of accepting Medicaid for reimbursements that do not cover their cost."

Stamper added that the current version of Medicaid coverage "does nothing to engage the beneficiary or incentivize behaviors that will lead to better health outcomes. A study that looked at the expansion population found that only 10 percent of Kentucky expansion beneficiaries received an annual wellness or physical exam. That is not the kind of utilization that will drive better health outcomes."

State Senate Floor Leader Damon Thayer, R-Georgetown, delivered a response to Beshear's response. It can be viewed on the state Republican Party's Facebook page.

Poll finds that most Kentucky adults have access to healthy foods, but most also don't eat enough fruits and vegetables daily

By Melissa Patrick
Kentucky Health News

Most Kentucky adults don't eat enough fruits or vegetables every day, even though most of them say they have easy access to them, according to the latest Kentucky Health Issues Poll.

"Too many Kentuckians still aren't getting their 'apple a day'," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, co-sponsor of the survey. "Federal guidelines say that half the food we eat each day should be fruits and vegetables, but only about one in 10 Kentuckians gets enough vegetables, and only a quarter of us get enough fruits."

The poll, taken Sept. 11 through Oct. 19, found that 42 percent of Kentucky adults don't get enough fruits and vegetables each day. and only 21 percent said they got enough of both.

Yet, 80 percent of those polled said it was easy to buy healthy foods, like whole grains, low-fat options and fresh fruits and vegetables. This number was 87 percent among those with higher incomes, 74 percent among those with lower incomes.

Lower-income people tend to have poorer health status, and the poll found that those who reported health status were more likely to say the cost of healthy food is too high: six in in 10, compared to about three in 10 of those who reported good, very good or excellent health.

"Cost is a barrier, but it's not the only obstacle to healthier eating," Chandler said. "The foundation is funding demonstration projects to provide education and enact healthy school-food policies in six communities statewide to help children establish better eating habits, and we're sharing what we're learning as part of our effort to change these statistics."

These numbers were largely unchanged from 2013, the last time the poll asked these questions. It is conducted by the Institute for Policy Research at the University of Cincinnati for the foundation and Interact for Health, a Cincinnati-area foundation. It surveyed a random sample of 1,580 adults via landlines and cell phones and has a margin of error of plus or minus 2.5 percentage points. Error margins for the smaller subsamples are larger.