New Medicaid boss, mentor Pence and Trump seek changes in program like some Bevin has asked her agency to approve for Ky.

Seema Verma (Getty Images)

By Al Cross

Kentucky Health News

The newly confirmed director of the nation's Medicaid program quickly served notice that she wants states to make changes like those she has helped make in Indiana and helped design in Kentucky, including work requirements. Then President Trump and key members of the U.S. House backed her up, in an effort to pass their initial bill to repeal and replace the Patient Protection and Affordable Care Act.

The Senate voted 55-43 Monday night to confirm Seema Verma, an Indiana health care consultant and protégé of Vice President Pence, to run the Center for Medicare and Medicaid Services. The next day, she and Health and Human Services Secretary Tom Price sent a letter to governors, "urging states to alter the insurance program for poor and disabled people by charging them insurance premiums, requiring them to pay part of emergency-room bills and prodding them to get jobs," Amy Goldstein reports for The Washington Post. The letter "also derides the Medicaid expansion that 31 states and the District of Columbia adopted under the Affordable Care Act."

Under Pence as governor and Verma as his consultant, Indiana expanded Medicaid, but under a federal waiver of certain Medicaid rules. Then Verma helped design a waiver request for Kentucky that would establish small, income-based premiums, impose work-related requirements and make other changes. That request is now pending before her agency, and Gov. Matt Bevin has suggested that it will not only be approved, but expanded to include other changes that the Obama administration frowned upon.

Critics of the Indiana plan say it "has been confusing for beneficiaries and some have incurred penalties through no fault of their own," reports Ricardo Alonso-Zaldivar of The Associated Press. "At her Senate confirmation hearing, Verma defended her approach by saying that low-income people are fully capable of making health care decisions based on rational incentives."

The letter from Verma and Price called for "a new era" in Medicaid "where states have more freedom to design programs." They said, "The best way to improve the long-term health of low-income Americans is to empower them with skills and employment."

However, "Such requirements would be nearly impossible to enforce, conservative and independent experts on the Medicaid program said Friday," Max Ehrenfreund reports for The Washington Post. "About 78 percent of adults enrolled in Medicaid who are not elderly live in households with at least one person working, according to an analysis by the nonpartisan Kaiser Family Foundation. Those who are not working might have good reasons for doing so, said Diane Rowland, an executive vice president at the foundation." The foundation says "about 18 percent of adult Medicaid beneficiaries who are not working are in school. Another 28 percent report that they are taking care of members of their family, and 35 percent say that they are sick or disabled." But work requirements are "a long-held goal of conservative reformers," Ehrenfreund reports.

To attract more votes from strongly conservative House members in a floor vote set for Thursday, March 24, Trump embraced amendments that the House Budget Committee said should be added to the bill. Those include allowing states to impose work requirements on healthy Medicaid enrollees who don't have dependents, Alan Fram and Erica Werner of The Associated Press report. Also, "The agreement would let states accept lump-sum federal payments for Medicaid, instead of money that would grow with the number of beneficiaries." However, "It seemed clear that GOP leaders remained short of the 216 votes they'll need, and additional changes were in the works."

Pence told a meeting of the financially conservative Club for Growth in Palm Beach, Fla., Saturday night, "We’re going to have an amendment to allow states to include a work requirement for able-bodied adults on Medicaid so we can ensure the program is there for people who actually need it." Earlier in the day, with Verma at his side, he told a crowd in Jacksonville, "We’re going to have an orderly transition to a better healthcare system in America that makes affordable, high-quality health insurance accessible for every American."

Beginning in 2020, the House Republican health-care bill backed by President Trump "would limit overall federal financing for Medicaid in the future. Taken together, those changes could leave 24 million more people uninsured by 2026, the Congressional Budget Office said Monday in an assessment," Goldstein notes. The impact would be greater in rural areas, The Wall Street Journal reports.

To see a Democratic-compiled rundown of how CBO thinks the bill would affect each of the 435 congressional districts, click here. Among Republican districts, Kentucky's 5th District has the third highest Medicaid expansion enrollment in the nation, about 105,000 out of the 440,000 expansion enrollees in Kentucky. The district also had the third largest decline in percentage of its population without health insurance, from 17.4 percent to 5.7 percent.

The 1st District, almost as rural, ranked 20th in decline of the uninsured, falling from 15.1 percent to 6.8 percent, with 76,000 in Medicaid expansion. The 2nd District was 25th, with an uninsured rate that dropped from 13.2 percent to 5.3 percent. It has 68,200 expansion enrollees. The 6th District has 75,100, the 3rd District 62,200 and the 4th District 53,000.

This story was first published on March 15 and was updated March 18, 19 and 20.

Legislature passes bill requiring ads against nursing homes to include their correction plan and when problem was corrected

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The 2017 General Assembly has passed two bills long supported by the nursing-home industry and other health-care providers -- one to impose another obstacle on medical-malpractice lawsuits, and one that would require law firms to publish "complete information" in advertisements about long-term care facilities. Both bills are on their way to Gov. Matt Bevin.

Sen. Ralph Alvarado

Senate Bill 4 would require a panel of three medical-care providers and a non-voting attorney to review a malpractice claim before submitting it to a court. The panel would have nine months to render an opinion, but could be bypassed if all sides agreed. Trial judges would decide on the opinion's admissibility.

Similar legislation from Republican Sen. Ralph Alvarado, a Winchester physician, had passed the Senate in earlier sessions, but wasn't heard in the House, which was led by Democrats. Both chambers now have GOP majorities, but some House Republicans doubted the measure's constitutionality, so it was amended in that chamber and passed by only 51-45, with 11 Republicans joining 34 Democrats in voting against it. The Senate concurred with the changes March 3.

Proponents of medical review panels say they will cut down on frivolous lawsuits and lower malpractice insurance costs. Opponents say such laws have proven ineffective in other states and that they delay a person's right to a trial by jury.

Sen. Danny Carroll

The "truth in advertising" legislation, SB 150, would require that any advertising about a long-term care facility that includes information about surveys, inspections or investigations, also include the date of any report, the facility's plan of correction and the date the deficiency was corrected. The ad must also state that it is not authorized or endorsed by any government agency. And all of this information must be in the same color, type font and size as the other language on the publication and be equally prominent.

The bill, which raises constitutional questions about freedom of speech, is aimed at ads from lawyers seeking plaintiffs to file lawsuits against nursing homes. It awaits Bevin's signature or veto.

The sponsor, Sen. Danny Carroll, R-Paducah, said during the bill's Senate hearing that most of these "unscrupulous and unethical" advertisements come from out-of-state law firms and that this measure "creates a level playing ground." In his legislative update, Carroll said this bill "will in no way restrict civil discourse or lessen accountability for long-term care facilities."

Bills can still be passed when legislators reconvene March 29 and 30 to reconsider any bills the governor has vetoed.

Alvarado is the sponsor of SB 18, which would ban doctors' peer reviews at hospitals from being used as evidence in malpractice cases.

Rep. Chad McCoy (Image from KET)

This bill has passed the Senate and a House committee and is before the House, with an amendment filed by freshman Rep. Chad McCoy, R-Bardstown, that would exempt statements of fact from the ban.

In effort to get around McCoy's amendment, language from SB 18 has been included in amendments to several other bipartisan bills that involve children. One of those includes House Bill 524, sponsored by Rep. Addia Wuchner, R-Florence, aimed at protecting children from sex trafficking. The bill awaits a vote on the Senate floor.

Legislature passes bills to name caregivers, help smokers quit; could still pass dense-breast notice and student-concussion bills

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Kentucky lawmakers have passed bills this year to make sure someone knows how to care for you when you leave a hospital, expand the role of pharmacists, increase access to smoking cessation, and offer some hope to terminally ill patients, among other health-related measures.

The bills now await Gov. Matt Bevin's signature or veto. Legislators will reconvene March 29 and 30 to reconsider any bills he vetoes; they could also pass additional legislation, but it would be subject to a veto without the opportunity for a override. Now that both houses of the General Assembly are controlled by the governor's party, such eleventh-hour legislation may be more likely.

Health bills that have passed

The "Kentucky Family Caregivers Act," Senate Bill 129, would require hospitals to record the name of a lay caregiver when a patient is admitted, notify that person when the patient is moved or discharged, and instruct the caregiver on the medical tasks he or she will need to perform when the patient goes home. The patient can decline this request. The bill, sponsored by Sen. Paul Hornback, R-Shelbyville. passed unanimously through both chambers and awaits the Governor's signature.

AARP, which supports this legislation, estimates that there are 650,000 family caregivers in Kentucky who save the state around $7 billion a year in health-care costs. AARP said in a statement that the bill will save even more money by improving post-discharge outcomes, reducing hospital readmissions and better allowing Kentuckians to recover at home, where they want to be.

The "Right to Try" bill, SB 21, also awaits the governor's signature. Sponsored by Sen. C.B. Embry Jr., R-Morgantown, it would make it easier for terminally ill patients to use experimental treatments. Terminal patients would be able to try drugs that have successfully completed the first phase of clinical trials but have not yet been approved by the U.S. Food and Drug Administration, with appropriate documentation from their health-care provider and approval of the drug company. The bill passed unanimously through the Senate and cleared the House 87-7.

"Right to Try" legislation has passed in 33 states and has been introduced in Congress, and has the support of Vice President Pence, Bloomberg News reports.

Kentucky lawmakers passed two bills that would expand the role of pharmacists.

SB 101, sponsored by Sen. Julie Raque Adams, R-Louisville, would allow pharmacists to administer all age-appropriate immunizations to minors aged 9 to 17. Current law allows pharmacists to administer flu vaccines starting at age 9, but for all other vaccines, pharmacists can only administer to minors starting at age 14. This bill unanimously passed both chambers and awaits the governor's signature.

SB 205, sponsored by Sen. Stephen Meredith, R-Leitchfield, would allow pharmacists to dispense a 90-day-supply of a non-controlled maintenance drug, such as those for blood pressure or high cholesterol, unless the prescription provides to the contrary. The bill passed unanimously in both Chambers and awaits the governor's signature.

Only one bill aimed at decreasing the state's high smoking rate has passed this session. SB 89, sponsored by Adams, would require all Kentucky health plans, including Medicaid, to provide barrier-free access to any smoking-cessation treatments approved by the U.S. Preventive Service Task Force. Some insurance companies have barriers to treatment, such as co-payments and prior authorizations. Bevin signed the bill March 21.

Health bills unlikely to pass

SB 78, which would have made Kentucky's schools 100 percent tobacco free, passed the Senate but couldn't get enough support among Republicans who control the House to be brought up in committee.

Two other bills aimed at protecting the health of children made no headway: House Bill 252, which would require an automated external defibrillator in every school; and HB 122, which would require children up to the age of 12 to wear a bicycle helmet.

Three bills that would increase the state's access to health-care providers also did not pass this session. SB 158 would repeal the requirement for nurse practitioners to work under a collaborative agreement with a physician to prescribe narcotics and some other controlled substances, and for the first four years of prescribing other drugs. HB 19 and SB 55 would have permitted physician assistants to prescribe and dispense controlled substance. The bills may have been hamstrung by the state's epidemic of opioid abuse.

Another bill that is dead this session is Senate Bill 108, dubbed the "Palliative Care" bill. This bill passed the Senate unanimously, but Rep. Addia Wuchner, chair of the House Health and Family Services Committee, says it needs more work. The bill's aim is to use training and education to increase access to palliative care, which is aimed at providing the best quality of life possible for patients with chronic or terminal diseases.

Health bills that could pass

One health bill likely to pass in the final two days is HB 78, which would require providers of standard mammograms to inform patients if they have "dense breast tissue" when appropriate, because such tissue can hide cancers. The notice would allow patients who have dense tissue the opportunity to determine with their provider if they need further screening.

Almost 40 percent of women have dense breast tissue, and some men do. They are twice as likely to develop breast cancer, Rep. Jim Duplessis, R-Elizabethtown, the bill's sponsor, said at the bill's hearings. The Dense Breast-info website says 27 states require some level of breast density notification after a mammogram. The bill passed unanimously through the House, passed a Senate committee and is before the full Senate.

Another bill that could pass would prohibit a coach from playing a student-athlete who has been diagnosed with or is suspected of having a concussion without written clearance from a physician. House Bill 241, sponsored by Rep. John Sims, D-Flemingsburg, passed unanimously in the House, passed a Senate committee and is before the full Senate.

This story was updated March 22.

Though more have insurance and can see a doctor, Ky. shows little gain on health outcomes; Chandler says that takes time

By Melissa Patrick
Kentucky Health News

The percentage of Kentuckians without health insurance has dropped by more than half since the implementation of the Patient Protection and Affordable Care Act three years ago, and few of the insured are having trouble finding a doctor when they need one, according to a report for the Foundation for a Healthy Kentucky.

However, the report also said little progress has been made to improve Kentuckians' health-care quality and health outcomes since the law was fully implemented in 2014.

"The ACA has led to clear progress for many Kentuckians in three of the five areas we tracked: insurance coverage, access to regular doctor visits and health-care costs for families," said Ben Chandler, president and CEO of the foundation. As for health-care quality and outcomes, he said, "Often, it takes longer to see these results; you don't turn around low birth weights or lengthen average lifespans in a couple of years."

The report found that since the implementation of the ACA, Kentucky's uninsured rate dropped to 6.1 percent from 13.6 percent. The highest coverage increase came in Medicaid and the Children's Health Insurance Program; 13.4 percent of Kentuckians had such coverage in 2012, and 19.8 percent had it in 2015.

Kentucky and other states that fully expanded Medicaid under the ACA saw the greatest increases in coverage. Neighboring states that expanded Medicaid had uninsured rates of 7 percent or lower; those that didn't, such as Tennessee, had rates of 9.1 percent or higher. It also noted that two neighboring states that expanded Medicaid through an "alternative" approach, like Kentucky has proposed to do, have uninsured rates similar to the non-exemption states.

The report also found that more Kentuckians said they had seen a health-care provider in the year prior to being surveyed (73.8 percent in 2012, rising to 78.7 percent in 2015) and fewer Kentuckians said they were delaying or skipping health care because they couldn't afford it (dropping from 11.7 percent to 6.5 percent). However, this wasn't true for the poorest and sickest Kentuckians who said health care cost still kept them from getting the care they needed.

Contrary to assertions by Republican Gov. Matt Bevin, the report says there is no evidence that the newly insured in Kentucky are having trouble finding a doctor when they need one, nor have they had an increase in average out-of-pocket spending on health care since 2012.

"Nearly 95 percent of Kentuckians could still find a doctor when they needed one," said Chandler, who voted against the ACA when he was a Democrat representing the 6th District in 2009.

Other improvements included fewer elderly Kentuckians delaying prescription refills or skipping or reducing medication doses because of high drug costs; a more than 500 percent increase in the number of covered substance-abuse treatments through Medicaid; a drop in the number of Kentuckians having trouble paying their medical bills; and lower monthly premiums in Kentucky's marketplace compared to most surrounding states and the U.S.

The report also looked at "quality-of-care" indicators and found they had neither improved nor declined since the ACA was implemented.

It noted that three of the quality measures that they looked at had "shown some progress," including the number of infants who were breastfed at discharge from the hospital, preventable hospitalizations due to high blood pressure, and asthma and colorectal screenings. It also noted that the state's smoking rate had dropped from 28.3 percent in 2012 to 26 percent in 2015, though the high-school student smoking rate had a smaller decline, from 17.9 percent in 2013 to 16.9 percent in 2015.

The report cites negative trends related to health behavior. Preventable hospitalizations due to short-term complications from diabetes increased, and the state's obesity rate rose from 31.3 percent in 2012 to 34.6 percent in 2015.

Chandler noted that some health measures, especially related to chronic health issues, may have worsened at first but then improved because many Kentuckians were seeing providers for the first time and were newly diagnosed. He noted that this increased access to care will ultimately improve the health of Kentuckians and decrease health care cost in the future.

"Myriad factors contribute to health and it takes time to change the tide in health outcomes," Chandler said. "In the long run, though, increased coverage, improved access and lower costs lead to better quality and outcomes. That's why I'm grateful Kentucky continues to support Medicaid expansion. We all want to sustain the gains we've achieved under the ACA and see the long-term benefits of increased coverage and access."

The foundation's study on the impact of the ACA over its first three years in Kentucky was conducted by the State Health Access Data Assistance Center at the University of Minnesota. Click here to see the full report.

Bill passes to decrease smoking; one doesn't; lawmakers set to pass resolution for feds to ditch plan to limit tobacco carcinogen

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Smoke-free advocates would say that this legislative session's record is 1-2.

That's because Kentucky lawmakers have passed one bill that will increase access to smoking-cessation treatments, but can't find enough support to pass one that would make Kentucky schools 100 percent tobacco-free -- and are poised to pass a resolution that asks federal officials to withdraw a proposal that would reduce the carcinogen levels in smokeless-tobacco products.

Sen. Julie Raque Adams' bill to decrease insurance barriers to smoking-cessation treatments is one of two tobacco-related bills that passed this legislative session and is on its way to the Governor for his signature.

The Patient Protection and Affordable Care Act requires all insurance policies to cover smoking-cessation treatments, but insurance barriers, like co-payments, prior authorization requirements and limits on length of treatment, make them not readily available.

Senate Bill 89 would require barrier-free access to all U.S. Preventive Services Task Force-recommended smoking cessation treatments in all Kentucky health plans, including Medicaid.

The other tobacco bill, sponsored by Sen. Ralph Alvarado, R-Winchester, which would have banned tobacco use on all school properties and at school events, is all but dead in the state House, despite its quick passage in the Senate.

Just over half of Kentucky's public-school students are in school districts with tobacco-free policies: 62 of the state's 173 districts, covering 654 schools.

Kentucky's high school students have a higher smoking rate than the national average, 17 percent compared to 15 percent; and 24 percent of them use electronic cigarettes, according to the 2015 Youth Risk Behavior Survey. The survey also found that 22.5 percent of the state's middle-school students have tried smoking.

Alvarado called Senate Bill 78 "low-hanging fruit" because it involves the health and safety of Kentucky's children and polling shows that 85 percent of Kentuckians support such an effort, but House Speaker Jeff Hoover said, "There was just not enough support in the caucus right now to do it."

Another piece of tobacco-related legislation introduced this session is a resolution that urges the the U.S. Food and Drug Administration to withdraw its proposal to reduce the levels of N-nitrosonornicotine, or NNN, a carcinogen, in all smokeless tobacco products sold in the U.S.

The FDA's proposal states,"NNN is a potent carcinogenic agent found in smokeless tobacco products and is a major contributor to the elevated cancer risks associated with smokeless tobacco. The FDA estimates that, in the 20 years following implementation of its proposed product standard, approximately 12,700 new cases of oral cancer and approximately 2,200 oral cancer deaths would be prevented in the U.S. because of this rule."

The resolution notes that the majority of farmers who raise the dark tobacco that makes up the main ingredient of smokeless tobacco products live in Kentucky and "raise approximately 24,000 acres of the crop with an estimated cash value of approximately $173 million per year."  It also says that the proposed standards in the FDA proposal are "technically unachievable" and that the impact of this rule would be "far-reaching and onerous because of the negative impact on agriculture and on manufacturing jobs in Kentucky."

House Concurrent Resolution 48, sponsored by Walker Thomas, R-Hopkinsville, passed the House 69-3 and is expected to pass the Senate in the final two days of the session, after the veto recess. The FDA is accepting public comment on this proposal until April 10, 2017. Click here for directions. 

Bill sent to Bevin would remove insurance-company barriers that keep Kentuckians from getting smoking-cessation treatments

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Kentuckians would have an easier time getting smoking-cessation treatments covered by insurance under a bill that is on its way to the governor's desk for final action.

"Senate Bill 89 is important so that Kentuckians are provided barrier-free access to proven smoking-cessation treatments," said Rep. Kim Poore Moser, R-Taylor-Mill, who presented the bill on the House floor.

The Patient Protection and Affordable Care Act requires all insurance companies to cover smoking-cessation medications and counseling, but they often erect barriers such co-payments and prior-approval requirements. The bill would remove barriers to all smoking-cessation treatments recommended by the U.S. Preventive Services Task Force.

Moser said passage of SB 89 would not only improve the health of Kentuckians, but would also save taxpayer dollars. Kentucky leads the nation in smoking, which she said cost the state $1.9 billion in annual health care costs and more than $500 million in Medicaid costs. She said the bill is preventive care "in its most basic form."

The bill is sponsored by Sen. Julie Raque Adams, R-Louisville, who is also the chair of the Senate Health and Welfare Committee. It passed the Senate 35-2 and the House 90-1.

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, applauded the bill's passage, saying it would "break down roadblocks that have made it harder for smokers to get the treatment they need to quit."

"The evidence shows that the most effective way to improve Kentucky's health is to reduce our smoking rates, which are the absolute highest in the nation," Chandler said. "Reducing smoking in Kentucky also will save billions in both insurance-company expenditures and taxpayer dollars."

Paul says conservatives won't support Republican health plan, hope to negotiate one more to their liking with Trump involved

Sen. Rand Paul (ABC image)

By Al Cross
Kentucky Health News

Republican U.S. Sen. Rand Paul laid out his objections to House GOP leaders’ bill to replace the Patient Protection and Affordable Care Act on CBS’s “Face the Nation” Sunday.

Paul called for an end to federal mandates for what insurance policies must cover, which the 2010 law called “essential benefits.” He said that change would enable consumers to buy the sort of coverage they want, at lower prices.

“Premiums will keep rising because they do nothing to fix the fundamental problem,” Paul told interviewer John Dickerson.

He also objected to the bill’s taxes, its “bailouts” for the insurance industry and the 30 percent surcharge that an insurance company could impose on someone who goes without coverage for more than 63 days in 12 months.

The surcharge is effectively a substitute for the current law that requires almost all Americans to have health coverage.

“The individual market will get worse when you get rid of the individual mandate,” Paul said, arguing that if someone loses a job, there will no incentive to sign up until coverage is needed. “You can’t have an insurance model where people wait ‘til they’re sick to get insurance,” he said.

Dickerson asked Paul about Medicaid, which covers 1.3 million Kentuckians, including 440,000 added through expansion of the program under the reform law.

The bill would set the first spending limits for the program, beginning in 2020, but Paul questioned whether the limits would be effective because the limit would rise with one measurement of inflation.

“It’s still building in the growth of an entitlement program that really isn’t paid for,” Paul said. “We have no money; we borrow a million dollars a minute.”

Paul, who has long made the federal deficit and the national debt his signature issue, shares those concerns with the House Freedom Caucus, a group of Republican representatives. Together, they pose significant obstacles to the bill, which is starting in the House.

If enough Republicans oppose the bill, it cannot pass. Paul said that if it is not changed, it will not pass, and that would begin talks that would include President Trump.

“I don’t think the president is rigid in support of the House bill. I think he's open to seeing how we can get consensus,” Paul said. “If enough conservatives to say no to the rule, then true negotiation begins.”

Paul was an apparent object of Vice President Pence’s Saturday trip to Louisville, hosted by Gov. Matt Bevin, who said Friday that he was closer to Paul on the issue.

Paul told Dickerson, “Right now I think there’s a charm offensive going on. Everybody’s being nice to everybody because they want us to vote for this, but we’re not going to vote for it.”

Pence touts Republican health plan, seeking Sen. Paul's support; Democrats say vice president's remarks about Ky. are off base

Gov. Bevin and Vice President Pence (C-J photo by Sam Upshaw)

By Al Cross
Kentucky Health News

Kentucky again became the epicenter of the health-care debate on Saturday, as Vice President Mike Pence claimed in Louisville that "Kentucky is a textbook example of Obamacare's failures," while Democrats said Pence didn't know what he was talking about.

"Obamacare has failed the people of Kentucky, Obamacare has failed the people of America and Obamacare must go!" Pence told an invited audience of more than 100.

Pence, until recently governor of Indiana, cited rising premiums for federally subsidized policies sold on government exchanges and Louisville-based Humana Inc.'s planned departure from the exchanges, and claimed "Nearly half of the state only has one health insurer to choose from."

That's true only in the number of counties with one Obamacare insurer; most of them are relatively small. Rep. Andy Barr, R-Lexington, defending the Republican replacement bill on CNN after the event, said incorrectly, "Here in Kentucky almost 50 percent of the people have only one choice."

Pence continued, "One-third of the state is on Medicaid, and as your governor has said over and over again, it’s unsustainable. And Medicaid here in Kentucky is threatening to bankrupt this state." For a transcript of Pence's remarks, go to http://kyhealthnews.blogspot.com/p/r.html.

Gov. Matt Bevin, who introduced Pence at the energy-management firm Harshaw Trane, has asked federal officials to let him scale back the Obamacare expansion of Medicaid by his predecessor, Democrat Steve Beshear. President Trump's administration is expected to approve the request.

"As Bevin and Pence were denouncing Obamacare, supporters unleashed a flurry of tweets citing benefits of the law in Kentucky," reports The Courier-Journal's Deborah Yetter. Outside the event, "More than 600 people gathered along the road," The C-J reported. "Many of the protesters chanted, 'Save our care'."

At a press conference after the Republican event, Beshear said the expansion has had a positive impact on the state budget and economy, by funneling billions of federal dollars into the state's health-care system. He said of Pence, "He apparently has decided to join the governor in ignoring the facts about how successful the ACA has been in Kentucky and instead enter the world of alternative facts."

Beshear noted that more than 500,000 Kentuckians gained health coverage under the ACA, and that the state "saw its uninsured population drop from about 20 percent to about 7 percent," James Bruggers writes for The Courier-Journal. "But Kentuckians also voted for Trump, who campaigned on a promise to repeal and replace Obamacare."

"Beshear acknowledged there were problems with parts of Obamacare, such as limited participation by insurance companies in some states or counties," Bruggers reports. "But he said Republican critics caused that by creating too much uncertainty. As a result, he said, some insurers 'are sitting on the sidelines'. He said he'd like the two parties to work together on solving those problems."

Rep. John Yarmuth of Louisville, the only Democrat in the Kentucky congressional delegation, told WHAS-TV, said the Republican bill "would devastate places like Kentucky, which have very poor populations and desperate need for health care."

Yarmuth said in a CNN interview that Obamacare "is definitely sustainable," but "Insurance markets need work." He said he favors allowing people to "buy into Medicare. But I don't get total agreement on that from many people."

Yarmuth said Pence came to put pressure on U.S. Sen. Rand Paul, who has called the Republican health bill "Obamacare lite." Paul said Saturday, "What's going on behind the scenes this week is a charm offensive." Paul will be on CBS's "Face the Nation" Sunday.

Pence didn't mention Paul in his speech, but said, "Now I know that not every politician in Kentucky supports our plan to repeal and replace Obamacare. I know your former governor, Steve Beshear has been defending Obamacare all over America." He called Beshear is a friend with whom he had worked, "but your former governor is wrong about Obamacare."

Pence complimented 2nd District U.S. Rep. Brett Guthrie, R-Bowling Green, for supporting the bill in committee. "We need every Republican in Congress, and we're counting on Kentucky," he said.

First District Rep. James Comer said in a brief interview Saturday that he was leaning toward supporting the bill. Fourth District Rep. Thomas Massie, R-Vanceburg, a Paul ally, told The Washington Examiner that the bill is "a stinking pile of garbage."

Bevin told reporters Friday that he is closer to Paul on the issue. "Senator Paul has ideas; he thinks it needs to be a lot stronger. He's not as impressed with what has currently been offered as some who have currently offered it. Truth be told, I'm not either, so I'm with him. I think there are things that need to be done. We don't need another version of the same thing."

Bevin said the Medicaid expansion "is not working well. It's coming at a price that's unaffordable . . . While we have enrolled a lot of people, we haven't made people healthier, we really have not, nor are we on track to do it, and we're on track basically to break the system."

Bevin has noted that few Medicaid members get regular checkups. On the other hand, a survey of low-income Kentuckians found they had become more likely to say they were in excellent health than their counterparts in Texas, which didn't expand Medicaid. The researchers wrote, "Significant impacts of Medicaid expansion may take several years to unfold."

Bevin also told reporters, "We have rural hospitals that, rather than becoming stronger, have failed since the implementation of this in Kentucky. We have doctors that have given up their practices; some have retired, some have sold out. We have fewer and fewer doctors who are even willing to see Medicaid patients." Bevin's office has not responded to a request for evidence supporting that statement.

American Health Care Act would have major impact on Ky. by phasing out Medicaid expansion, changing private insurance

By Danielle Ray and Al Cross

Kentucky Health News

The acronyms may be similar, but the American Health Care Act, Republicans' replacement for the Patient Protection and Affordable Care Act, would overthrow some core tenets of "Obamacare" and have major impacts on Kentucky.

The ACA and the AHCA are mainly about the individual health-insurance market, where about 7 percent of Americans get coverage, but in Kentucky, the law's biggest impact is the expansion of the federal-state Medicaid program. About 440,000 Kentuckians get free health care through the expansion, while only 82,000 are enrolled in Obamacare plans subsidized by federal tax credits.

Medicaid expansion would be phased out

Under the ACA, Kentucky and 30 other states expanded Medicaid to people with incomes up to 138 percent of the federal poverty level, now $16,394 for an individual or $33,534 for a family of four.
Under the ACA, this would be phased out over time, and open-ended federal funding for the states would be replaced with block grants based on a certain amount per Medicaid member.

The block grants would grow more slowly than actual costs, so states would have to pay progressively more or reduce expenses, explains Harris Meyer of Modern Healthcare. The bill would increase the percentage of people who are uninsured and raise uncompensated-care costs for hospitals and other health-care providers, Modern Healthcare reports.

Providers and patient-advocacy groups worry that the block-grant structure would drastically cut funding over time, forcing states to cut eligibility, benefits and provider payments. The American Hospital Association, the Catholic Health Association, America's Essential Hospitals and the Association for Community-Affiliated Plans have all come out in opposition to the bill in its current form, citing concerns about Medicaid, Meyers reports.

Because Medicaid has considerable turnover, as people gain or lose eligibility or choose to enroll or not, the number of people on the expansion would decline over time. The Congressional Budget Office has yet to estimate how many people would lose coverage or how much the bill would cost.

The organizations that oppose the proposed changes to Medicaid have urged lawmakers to wait for the CBO to score the bill's impact on spending and coverage levels. An early analysis from S&P Global Ratings estimates that four million to six million people now enrolled in Medicaid would lose coverage under the AHCA.

Drug treatment: The bill would eliminate the existing requirement that Medicaid cover basic mental-health and addiction services in states that expanded it, letting the decide whether to include those benefits. This point is of particular concern in states like Kentucky that have been hit hard by the opioid crisis and thus have a greater population in need of addiction treatment services.

"With Kentucky's current opioid epidemic, we can't afford to go back to the days when people had no way of getting substance use treatment or behavioral health services," Dr. Sheila Schuster, board chair of Kentucky Voices for Health, said in a news release on Wednesday. "Over time, Medicaid cuts would give us far fewer options to meet the needs of Kentuckians."

(Image from Twitter; click on it for a larger version)

Politics: The Republican bill would stop expansion enrollment on Jan. 1, 2020, but conservatives have objected to the delay, and "White House officials are beginning to urge House GOP leadership to include an earlier sunset of the Medicaid expansion," reports Jeremy Diamond of CNN. But Greg Sargent of The Washington Post writes, "This would mean that the fallout hits right amid the 2018 midterm elections, something that could not only impact the congressional and Senate races, but also the hugely consequential 2018 gubernatorial contests, in which repeal of the Medicaid expansion could create major complications."

An earlier phase-out of Medicaid expansion would also complicate prospects for the bill in the Senate, where several Republicans want to protect it for their states and GOP leaders can't afford to lose more than two GOP votes. (Kentucky Sen. Rand Paul is expected to be one; he called the bill "Obamacare Lite" in a tweet on Tuesday, and expressed disapproval of its ACA holdovers.) However, the Senate could take a more moderate stance once it gets the bill and pressure the House to accept that version, NBC reports.

How money would flow: Under the AHCA's per-capita grant model, states would receive a flat amount of federal dollars for each of five Medicaid beneficiary groups: the elderly, blind and disabled, children, adult expansion beneficiaries and adult non-expansion beneficiaries. States would then decide whom to cover, which benefits to offer and how much to pay providers.

The bill would use fiscal year 2016 as a baseline for each state's per-capita spending for each of the five beneficiary groups. Those baseline figures would then be trended forward to fiscal year 2019. In 2020, the Department of Health and Human Services would use those figures to compare a state's spending target with its actual per-capita spending. The target would be calculated using the medical component of the Consumer Price Index, which lags behind actual Medicaid per-capita costs, Meyer notes.

"If a state's per-capita cost growth exceeded the target, the federal government would take back its excess payments by reducing its contributions in each quarter of the following year," Meyer reports.

Private insurance would change

One of the biggest changes to private insurance would be how policies are subsidized. The existing program uses advance tax credits to help offset out-of-pocket costs. The tax credits are based on age, income and local insurance prices. (Learn more about how tax credits are calculated here.) The AHCA would offer tax credits based only on age, and with a different structure.

Graphic from The Economist

Lower-income people would get lesser tax credits than they do now, and credits would be available to higher-income people who don't get them now. Tax credits for small businesses would be eliminated.

Individuals with modified adjusted gross incomes under $75,000, or married couples with MAGI under $150,000, would get the same, fixed amounts for their age groups. People above those thresholds would have their tax credit would be reduced by 10 percent of the income above the threshold.

Tax credits would start at $2,000 a year for people under age 30, increasing in $500 increments per decade in age, up to $4,000 a year for people 60 and older. The credits would be limited to $14,000 per family, FactCheck.org writers explained in USA Today. The new structure would take effect in 2020, with modifications in 2018 and 2019 to give more to younger people and less to older people.

Rural areas are more vulnerable than urban areas to cuts in subsidies because the existing program takes local insurance costs into account and the AHCA does not. Counties in western, southern and southeastern Kentucky are particularly vulnerable to such scenarios. Find out how your county would be affected with this interactive county-by-county map from the nonpartisan Kaiser Family Foundation.

Critics say this structure hurts low-income Americans and benefits the wealthy. "Kentucky has gained more from the Affordable Care Act . . . than any other state, and we have more to lose from its repeal," Jason Bailey of the liberal-leaning Kentucky Center for Economic Policy said in a news release. "The new House proposal is a plan to give tax breaks to the wealthy paid for by dramatically reducing the number of people with health coverage."

The AHCA would allows for a wider range in insurance pricing; insurers could charge older individuals up to five times as much as younger people, and states could change that ratio, FactCheck notes. Under current law, the ratio is three-to-one. Thus, young people could see lower premiums while older ones could see higher premiums.

Other provisions: In addition to tax credits, current law offers cost-sharing subsidies to reduce copayments and other out-of-pocket costs for people earning between 100 percent and 250 percent of the federal poverty level. The AHCA would eliminate those subsidies in 2020 but create a Patient and State Stability Fund with $100 billion over nine years that could be used for various purposes, including mitigating out-of-pocket costs.

The AHCA would increase the amount that could be put into tax-exempt health savings accounts, now $3,400 for individuals and $6,750 for families, to $6,550 and $13,100, respectively. The bill also aims to allow people to use HSA money for over-the-counter drugs. Current law allows HSA money to be used for an over-the-counter drug only if the patient first received a prescription for it.

The bill would eliminate the requirement that almost all Americans have health-insurance coverage, but would encourage people to remain insured by letting insurance companies charge a penalty for not having continuous coverage. Insurers could charge 30 percent higher premiums for one year, regardless of health status, to people entering the individual market who had a lapse of coverage of 63 days or more during the previous 12 months.

An early analysis from S&P estimates that 6 million to 10 million fewer people will have health-insurance coverage as a result of the bill. Read a detailed summary of the AHCA here.

Kentuckians on public insurance such as Medicaid used ERs more often after full implementation of the Affordable Care Act

Use of emergency rooms was expected to decrease after the implementation of the Patient Protection and Affordable Care Act, but it rose among people with public insurance such as Medicaid, according to a report for the Foundation for a Healthy Kentucky.

One in four Kentuckians in 2015 said they had visited an ER in the past year, about the same proportion as before the ACA was implemented in 2014. The 25.5 percent rate was "significantly higher" than the national rate of 18.3 percent, said the report by the State Health Access Data Assistance Center at the University of Minnesota.

Among people with public insurance, the ER usage rate rose to 41.3 percent from 34.5 percent. Among those with private insurance, it fell to 15.2 percent from 17.4 percent.

Supporters of the law said that as more people became insured, the more likely it would be that they would find a medical home to meet their health-care needs. "One of the benefits supporters hoped would result from the ACA was reduced use of ERs, where treatment is a lot more expensive," Foundation CEO Ben Chandler said in a news release. "What we found is that ER visits declined for several months after the ACA first went into effect, but then they rose again."

The study found that since the implementation of the ACA in 2014, the total number of ER visits dropped during the first three quarters of 2014 and then rose to a level in 2016 that was 4.5 percent higher than in 2012.

The survey asked Kentuckians why they went to the ER. Nearly three in 10 said they went because of a medical emergency. About the same number said they went because no other facilities were open when they needed care. Only 3 percent used the ER because they didn't have a regular doctor; another 3 percent said they used the ER because it was close by. Seven percent said they went because their doctor told them to, and 3 percent said they were taken by an ambulance.

"The explanations are multifaceted, but it turns out Kentuckians had some very rational reasons for heading to the ER," Chandler said. "The bottom line is that many of the benefits of having insurance coverage for the first time in life will take a while to play out, and that's certainly the case with ER use."

For hospitals, the difference is that they are being paid for many ER visits because more patients have insurance. Kentucky has had the largest drop in the number of uninsured in the nation since the ACA, dropping from 20.4 percent in 2013 to 7.8 percent in 2016, according to Gallup.

The study found that the proportion of ER visits that hospitals reported as charity care or self-pay dropped from 23 percent in 2012 to less than 6 percent by the third quarter of 2016. Meanwhile, visits covered by Medicaid rose from almost one-third in 2012 to almost half in 2015 and 2016.

"Hospitals have benefited from the ACA because they're having to eat less of the cost of caring for uninsured Kentuckians," Chandler said. "That's especially important for smaller, rural hospitals."

The report, "Emergency Department Utilization in Kentucky," is part of the foundation's ongoing study of the impact of the ACA in Kentucky.

Bill to make all Ky. schools tobacco-free is likely dead for this session; only 62 of the state's 173 school districts ban tobacco

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill that would ban tobacco use on school properties and at school events has all but died in the state House, despite its quick passage in the Senate and polling that says Kentuckians would support such a mandate.

"We are probably not going to do that this session. . . . unless there is a change of direction in the caucus, we are probably not going to do that," House Speaker Jeff Hoover said. "There is just not enough support in the caucus right now to do it."

Senate Bill 78 would prohibit the use of tobacco products by students, school personnel, and visitors in schools, school vehicles, properties, and activities, allowing schools one year to adopt, implement and enforce the policy. Just over half of Kentucky's public-school students are in school districts with tobacco-free policies: 62 of the state's 173 districts, covering 654 schools.

The bill passed unanimously out of the Senate Education Committee and passed the Senate 25-8, with two members passing. It now resides in the House Education Committee.

The committee chair, Rep. John "Bam" Carney, R-Campbellsville, said he supports the bill, but the decision to put it on his committee agenda or not depends on leaders of the House's Republican majority, who determine the "pulse" of the caucus on the issue.

"Personally, I would be glad to hear it," Carney said. "It is certainly something that I would probably vote for."

Majority Floor Leader Johnathan Shell, R-Lancaster, said the bill isn't a priority.  "We have got so many more important bills that have been coming in and out," he said. "We are just trying to make sure that we are getting everything through the process that we can."

Freshman Rep. C. Wesley Morgan, R-Richmond, concurred with Shell, saying he thought the bill was probably being held up "because there has been a lot of substantial bills related to a lot of things that have been held up for a long time that have really high priority."

Sen. Ralph Alvarado

The bill's sponsor, Sen. Ralph Alvarado, R-Winchester, said Kentucky is missing out on an opportunity to decrease youth smoking -- which would save lives in future generations -- and to decrease the cost of health care in the future.

"I think reducing the youth smoking rate would be the biggest long term investment for us, but it has got to start at some point," he said. Research shows that strictly enforced tobacco-free school policies can reduce youth smoking by 30 percent.

Kentucky's high-school students smoke at a higher rate than the national average, 17 percent compared to 15 percent; and 24 percent of them use electronic cigarettes, according to the 2015 Youth Risk Behavior Survey. The survey also found that 22.5 percent of the state's middle-school students have tried smoking.

Morgan, a former smoker, said he would support such a bill, and had been approached by supporters of the bill, but no one had lobbied him against it.

Rep. Kim P. Moser, R-Walton, who is carrying the bill for Alvarado in the House, also said she had not heard of anyone lobbying against it.

Rep. Stan Lee, R-Lexington, also a former smoker, said he wasn't familiar with the bill, but noted that resistance to bills that restrict tobacco use in Kentucky was often cultural.

"The struggle I have is that I grew up on a tobacco farm. It put food on the table and clothes on my back. . . . I still have that issue that it is a free and legal product, " he said. "I would say probably that the real reason that it is not moving is that it is cultural."

Alvarado, a physician, said he thought one of the reasons the bill has been held up in the House is because of a misconception that it says possession of tobacco products on school grounds would be a violation of the law. That is not true, he said: "If you are consuming tobacco products, that is where it would become an issue on campus."

Alvarado said he was hanging onto a "slim hope" that the bill could be called up in the House. Legislators have two days left in this short session, March 14 and 15, to pass laws without subjecting them to a veto by the governor that wouldn't be overridden.

He called the bill "low-hanging fruit." It does seem to be politically popular, since 85 percent of Kentuckians support tobacco-free schools, according to the 2016 Kentucky Health Issues Poll.

Another tobacco bill: Sen. Julie Raque Adams, R-Louisville, has filed a tobacco related bill, Senate Bill 89, that would require all insurance policies sold in Kentucky to cover all smoking-cessation medications and counseling approved by the U.S. Food and Drug Administration, eliminating many current barriers to treatment, like co-payments and prior authorization. This bill passed 35-2 in the Senate, passed favorably out of its House committee and is awaiting action in the full House.

Ky. enrollment in Obamacare plans slightly less than last year

About the same number of Kentuckians signed up for subsidized health insurance on the federal health-insurance exchange as bought coverage on the state's Kynect exchange last year, state health officials announced Tuesday.

The Cabinet for Health and Family Services said 81,155 Kentuckians enrolled in federally qualified health plans on www.healthcare.gov during the three-month enrollment period that ended Jan. 31. That was 1.8 percent less than the year before, when 82,681 Kentuckians bought a plan on Kynect.

“These numbers clearly show the transition to the federal marketplace was a success,” cabinet Secretary Vickie Yates Brown Glisson said in a news release. “We have worked very hard to make sure this change produced minimal impact on consumers so that, at the end of the day, someone purchasing insurance through the federal marketplace was simply moving from one website to another.”

Gov. Matt Bevin pledged to close Kynect, but didn't go quite that far. He kept the exchange for insurance companies, which wanted a state-based exchange, but shifted consumers' enrollment to the federal exchange.

Under that setup, the federal government handles consumers' eligibility appeals, but the state reviews insurance companies' plan offerings and handles insurance-company grievances. Consumer grievances are handled by a state-federal partnership.

Kynect was funded by a 1 percent fee on all health-insurance policies sold in the state. Bevin said it wasn't fair for all insurance customers to pay for an exchange that 82,000 people use. However, his administration left the the fee in place, saying it is needed to help pay transition costs, fund the Kentucky Health Information Exchange and fund "legacy costs" of Kentucky Access, the high-risk insurance pool for which the fee was originally established – and transformed into Kynect funding by an executive order from then-Gov. Steve Beshear.

Ben Chandler, president of the Foundation for a Healthy Kentucky, hailed the enrollment numbers, but noted implicitly that the main impact of Obamacare in Kentucky has been Beshear's expansion of Medicaid to people with household incomes up to 138 percent of the federal poverty level.

“It's great news that enrollment in marketplace health plans this year is comparable to last year,” Chandler said. “The idea is to get more people insured, and this news is evidence that's happening. Toward the same goal – getting more people covered – we are pleased that Gov. Bevin is working to keep Medicaid expansion in Kentucky. Our research shows that the number of Kentuckians covered by Medicaid has increased by more than 500,000 people since 2010.”