Report offers Appalachian residents ways to decrease smoking rates; they are more likely to die from smoking-related diseases

By Melissa Patrick
Kentucky Health News

It's well documented that people in Appalachia die sooner than other Americans, and are more likely to die from smoking-related diseases. It doesn't have to stay that way; a new report offers a detailed list of strategies and policies proven to decrease smoking, the cause of many premature deaths.

The report was created by Appalachian Regional Commission, the Foundation for a Healthy Kentucky and the Robert Wood Johnson Foundation.

The report notes that in 2014, about 20% of Appalachian adults were smokers, compared to 16% of adults elsewhere in the U.S. Those rates were highest, 25%, in Central Appalachia, the subregion of the ARC service area that includes all of Kentucky's Appalachian counties.

The report adds that smoking is a key factor in deaths from heart disease, cancer and chronic lower-respiratory disease, which are three of the four leading causes of death in the U.S., and that these diseases occur more frequently in Appalachia than in the rest of the country.

As a way to decrease smoking-related deaths, the report recommends four approaches to reduce smoking in the region: youth prevention, increased access to tobacco cessation, strong anti-tobacco campaigns and policies that decrease exposure to second-hand smoke.

"Here is a fresh set of evidence, practical advice, and local examples of the tactics and tools Appalachian communities have used to reduce tobacco use and improve health," Ben Chandler, president and CEO of the foundation, said in a news release. "Some of Appalachia's most glaring health disparities are found in the central region that includes Kentucky and West Virginia, so the approaches can have an outsized benefit here."

Before settling on any of these approaches, the report encourages communities do a "community needs assessment" to best determine which strategies their residents are willing to undertake. The report offers tips and links on how to do such an assessment; recommendations for funders; and links to state- and county-level data on a range of tobacco and health related topics.

The report offers several community-based strategies to decrease youth smoking, which is important because 90% of adults report they started using tobacco products when they were teens.

Suggested youth prevention strategies included educating parents, teachers, health professionals and youth about the risks of smoking and electronic cigarettes, restricting access and expanding smoke-free policies. The report also encourages Appalachian communities to form coalitions to promote and support these strategies.

The General Assembly recently passed a law to ban the use of all tobacco products in all Kentucky public schools and events. It will go into effect July 1, 2020 and gives school boards three years to opt out.

Policy-based strategies in the report include raising the minimum age to buy tobacco products from 18 to 21 and increasing the price of tobacco products. In Kentucky, such policies would have to be passed statewide since state laws pre-empt any local regulations on distribution, sale and regulation of tobacco products.

Last fall's Kentucky Health Issues Poll found that 66% of Kentucky adults supported such a law and 30% opposed it. Bills to raise the age to buy tobacco products from 18 to 21 have been introduced for several years, but haven't gained much traction.

As for raising the cigarette tax, it's not likely that Kentucky's lawmakers will do that again anytime soon since they increased it by 50 cents to $1.10 per pack in 2018, which at 83 percent was the largest increase in the state's history.

The report also advises Appalachian communities to increase their access to tobacco-cessation products. One way it says to do this is to partner with work and faith-based organizations. As an example, the report points to the Faith Moves Mountains program, which provided cessation treatment to 590 smokers across 26 rural churches in Appalachian Kentucky. The state has a quitline (1-800-QUIT-NOW).

Further, the report says Kentucky serves as an example of how states can pass laws to reduce out-of-pocket costs for cessation treatment, pointing to Senate Bill 89, which requires all insurance policies sold in Kentucky, including Medicaid, to cover all tobacco cessation services recommended by the U. S. Preventive Services Task Force.

Medicare was not included in this bill, but anyone on Medicare, or Kentuckians who are uninsured, can call the quitline to get access to cessation treatments.

The report also encourages Appalachian communities to launch anti-tobacco communication campaigns that are designed to resonate with their local residents, as some have done with the "tobacco prevention barns" found throughout Appalachia.

It also recommends implementing policies that reduce exposure to secondhand smoke. As of April 1, 35.5% of Kentuckians are protected by smoke-free laws covering all indoor workplaces and public spaces.

Kentucky has 16 confirmed cases of salmonella from pre-cut melons; health officials say you should throw it all out

CNN image

Health officials are advising Kentuckians to throw away all of their pre-cut cantaloupe, watermelon and honeydew, since 16 cases of salmonella have been linked to these products.

The Kentucky Department of Public Health advises that all pre-cut melon be thrown out because the label may not clearly indicate that the product came from Caito Foods from Indianapolis, which distributed the fruit. The products have been sold under several brands and labels.

Caito issued a voluntary recall of these pre-cut melons April 12 in 16 states, including Kentucky. The recall also advises stores to quit selling these products. The recall does not include whole melons.

Salmonella Carrau is a bacteria that makes people sick. Symptoms usually develop 12 to 72 hours after exposure and include diarrhea, fever and stomach cramps. The illness usually lasts four to seven days. Children under 5, adults older than 65 and those with weakened immune systems are at the greatest risk of being severely affected. The release notes that most adults recover with antibiotics.

These infections are part of a nine-state salmonella outbreak that have all been linked to the pre-cut fruit. So far, the Centers for Disease Control and Prevention reports that 93 people have been infected with the disease and 23 people have been hospitalized because of it. No deaths have been reported. Most of the sick have been adults over 50.

“Exposure to salmonella bacteria can be debilitating and potentially life-threatening, especially for small children and individuals with weakened immune systems,” Dr. Jeff Howard, the state's public-health commissioner, said in a news release. “Anyone experiencing signs or symptoms of illness should seek medical care and clinicians should be aware of this ongoing outbreak to ensure suspected cases receive testing and investigative follow-up."

The news release notes that salmonella infection is an extremely common infection in the Kentucky so lab testing is needed to confirm if an illness is linked to this outbreak.

Eight Kentuckians among 60 indicted for illegal prescribing or health-care fraud as a result of major federal investigation

Rob Duncan, U.S. attorney for the Eastern
District of Kentucky, announced the cases.
(Associated Press photo by John Minchillo)

Sixty health professionals in five Appalachian states, including Kentucky, were charged Wednesday with "illegal prescribing of more than 32 million pain pills, including doctors who prosecutors said traded sex for prescriptions and a dentist who unnecessarily pulled teeth from patients to justify giving them opioids," report Sari Horwitz and Scott Higham of The Washington Post.

Those indicted included "31 doctors, seven pharmacists, eight nurse practitioners and seven other licensed medical professionals" who wrote more than 350,000 illegal prescriptions in Ohio, West Virginia, Kentucky, Tennessee and Alabama, according to federal indictments filed in Cincinnati. “That is the equivalent of one opioid dose for every man, woman and child in the five states in the region that we’ve been targeting,” Brian Benczkowski, the assistant attorney general in charge of the Justice Department’s Criminal Division, told the Post.

Those indicted in Kentucky, according to the USA Today Network, include:

•  Dr. Denver Tackett, who ran a dental clinic in McDowell, is accused of prescribing Oxycodone and hydrocodone that were not reasonable for the treatment of a patient's illness or injury. He also is accused of pulling teeth from six patients who had no need for extractions, as well as submitting claims to Medicare and Medicaid for procedures he did not perform.

•  Dr. Christopher Nelson of Louisville's Bluegrass Pain Consultants, is accused of teaming with a Florida pharmacy, AssuredRx, to defraud Medicare and Tricare, a health-insurance plan for veterans, by inflating drug costs. Nelson is accused in a kickback and bribe scheme to funnel customers to Assured Rx for drugs used for pain, including controlled substances. Nelson has pleaded not guilty.

•  Dr. Ijaz Mahmood, who operates a clinic in Elizabethtown, charged with authorizing prescriptions for drugs, including controlled substances, through presigned, blank prescriptions and directing employees, including some who weren't licensed to practice medicine, to perform medical services on patients. Mahmood told a Courier Journal reporter that he didn't want to discuss the charges.

•  Dr. Scotty Akers and Serissa L. Collier, who also used the last name Stamper, are charged in an indictment with distributing the opioids hydrocodone, oxycodone and fentanyl between August 2016 and May 2018. Both are from Pikeville.

•  Dr. Mohammed A.H. Mazumder of Prestonsburg, who owned Appalachian Primary Care, is charged with telling his employees, who were not doctors, to receive patients at the clinic when he was not there. The indictment says a medical technician evaluated patients, then two receptionists called pharmacies with prescription orders for opioids and other controlled substances under Mazumder’s name. The clinic then submitted claims to Medicare and Medicaid as if Mazumder had examined the patients and ordered the prescriptions.

•  Dr. Sai P. Gutti, who has offices in Pikeville, Harold, Paintsville, Whitesburg and Belfry and also saw patients in Frankfort and other Kentucky towns, is accused of eight counts of health-care fraud by ordering medically unnecessary drug tests for Medicare and Medicaid patients.

•  Gary Green of Louisville is accused of failing to inform the Drug Enforcement Administration when he transferred and stored controlled substances in the offices of Guaranteed Total Construction, for which he acted as a registered agent; of furnishing false and fraudulent information in, and omitting material information from documents required to be made, kept, and filed.

The Justice Department says it has targeted doctors, health-care companies and drug manufacturers and distributors for their roles in the opioid epidemic that killed 47,600 Americans in 2017. "Benczkowski said he created the Appalachian Regional Prescription Opioid Strike Force late last year to target the region, which has been devastated by the epidemic," the Post reports. "The department analyzed several databases to identify suspicious prescribing activity and sent 14 prosecutors to 11 federal districts there. . . .Once they had the data indicating suspicious prescriptions, investigators used confidential informants and undercover agents to infiltrate medical offices across the region. Cameras and tape recorders were rolling as they documented how medical professionals used their licenses to peddle highly addictive opioids in exchange for cash and sex, officials said."

The indictments merited a statement from Attorney General William Barr: “The opioid epidemic is the deadliest drug crisis in American history, and Appalachia has suffered the consequences more than perhaps any other region.”

Keynoter at harm-reduction summit says syringe exchange programs need to partner with drug users to be truly successful

By Melissa Patrick
Kentucky Health News

COVINGTON, Ky. – Syringe exchange programs must partner with drug users to have the most impact. That was one of many messages that resonated with the nearly 500 attendees of the state-sponsored 2019 Harm Reduction Summit in Northern Kentucky on April 9.

Nearly 500 people attended the 2019 Harm Reduction Summit
on April 9 in Northern Kentucky.  (Photo by Melissa Patrick)

Jon Zibbell, a senior public-health scientist at RTI International, an independent, nonprofit research institute, was the keynote speaker. He praised the state's efforts for harm reduction, saying Kentucky is recognized across the nation as a leader on it.

At the same time, he stressed that there is room to do more in these programs to better meet the needs of the people they are supposed to serve. But first, he said, you have to ask the people who use drugs what their needs are.

"This population has insights and expertise that can help inform the planning, delivery and review of harm reduction services," Zibbell said.

Harm reduction is the primary purpose of a syringe exchange. It not only passes out clean needles and syringes as a way to decrease the spread of HIV and hepatitis C, which are commonly shared by the sharing of needles among intravenous drug users; it also provides health screenings and vaccines, access to treatment, and a safe place for people to reach out for help.

The legislature authorized the exchanges in 2015, subject to approval of local governments. They have approved 52 exchanges, all but four operational. That said, about half of the 54 counties that are considered at high risk for HIV and hepatitis C outbreaks among IV drug users still don't have one.

Latest, updated map of syringe exchanges and vulnerable counties (Click on it for a larger version)

Zibbell talked about the many challenges of helping drug users stay safe, including the influx of fentanyl into the market, which has created what he called "market unpredictability;" the use of multiple drugs among opioid users, which increases their risk for overdose; and the increase in the number of non-opioid drugs, like cocaine and methamphetamine, that also have fentanyl in them.

He said no one knows better than the drug users themselves the reality of these challenges, and that's why we need to be talking to them about it.

Zibbell said much of the data used by harm-reduction programs comes from law enforcement, government data sets and mortality records, not the people on the streets who "have critical knowledge and expertise. . . . People that use drugs have an insight and a knowledge about drugs that we desperately need."

He said the principles of harm reduction support his call for bringing drug users into the programs as consultants. One calls for drug users and those with a history of drug use to "routinely have a real voice in the creating of programs and policies designed to serve them." Another says users are called to be the "primary agents of reducing the harms of their drug use," and such programs should empower them to share information and support each other with strategies to do so.

Zibbell said working in partnership with people who use drugs helps a program better understand its clients and their needs, which will result in better outreach and service. Further, he said it will ensure the program is community-friendly, improves the "cultural competency" of the workers and reduces the stigma often associated with drug use.

"We need to know where the drugs are on the street, we need to know how people are injecting, we need to know if people are getting tested, if they've been vaccinated," he said. "Having that connection to the population gives us that entry. "

Takeisha Nunez, supervisor of the syringe exchange at the Louisville health department, also came with the message of partnering with drug users. Her focus was on African Americans, who she said have been slow to embrace them.

Nunez said African Americans' historical mistrust of government and the medical system has been an obstacle for them to participate in syringe exchanges, which in Louisville are primarily located in government buildings or medical centers.

In response to a Facebook question about why more African Americans don't come to the Louisville exchange, one client replied: "They are afraid. I have shown them my card and everything, but they don't believe that they won't get arrested."

Further, she said there is a lot of resentment about these programs. Another person on Facebook wrote, "Where was all this compassion when there was a crack era and you was locking up the black and brown people? No one was the angel of compassion for our community."

Nunez said, "We have to figure out ways to break down those barriers."

What you're not eating may be killing you

Bloomberg: What You're Not Eating May Be Killing You

Moderate drinking increases risk of stroke, study says

USA Today: No, moderate drinking can't protect against stroke. It actually increases risk, study says

Bevin signs bill making all Ky. school property and events free of tobacco and e-cigs by July 2020, unless school boards opt out

By Melissa Patrick
Kentucky Health News

Gov. Matt Bevin has signed into law to ban the use of tobacco products in all Kentucky public schools and events, a policy that has taken several years to pass. It will take effect July 1, 2020.

Rep. Kim Moser

"It's not only going to help kids become less addicted in the future and improve overall health, but I think it will actually improve the light in which Kentucky is looked upon as a healthy state," said state Rep. Kim Moser, the bill's sponsor. "I really feel like this is a step in the right direction and I just think the messaging is so critical, especially for kids."

Moser, a Republican form Taylor Mill in Northern Kentucky, said it's important to recognize that e-cigarettes and other tobacco products not only create what are often life-long addictions to the nicotine, they also can prime the adolescent brain for addiction to other drugs.
.
Moser and Sen. Ralph Alvarado, Bevin's running mate for lieutenant governor and a longtime advocate for tobacco-free schools, said the alarming increase in teenagers' electronic cigarette use in the last year was likely the main reason the bill was able to pass this year.

"The more people started realizing what a problem this is, I think that really shed a lot of light on this whole tobacco-use issue," Moser said.

Sen. Ralph Alvarado

Alvarado, a Winchester physician, credited a group of Johnson County Middle School students for educating legislators on the rampant use of e-cigarettes in schools. Among other things, they told them that some students have become so addicted to the nicotine that they can't even make it through one class without going to the bathroom to use a device.

The most popular device for teens, made by Juul Labs, is easy to hide because it looks like a large computer flash drive. One Juul pod has the equivalent of a pack of cigarettes, and some kids are going through about eight a day, Alvarado told lawmakers on the Senate floor.

The students were actually pushing a Senate bill that would have created an anonymous hotline for students to report concerns about e-cigs and tobacco use . The bill made it all the way to the House floor, but wasn't called up for a vote. Alvarado, who presented the tobacco-free schools bill in the Senate, said he planned on inviting the students to the ceremonial signing of the bill because of the role they played in getting it passed.

"I think they gave everybody a little insight on what happens in the classroom, what happens on school grounds," he said. "I think they also had an instrumental part in being able to open some folks eyes in terms of how big this problem is becoming with vaping and tobacco use in our schools."

The tobacco-free schools measure, House Bill 11, prohibits the use of all tobacco products, including electronic cigarettes, on school-owned property and school-sponsored events in all Kentucky schools. Tobacco use will be permitted on field trips that are off school property if students are not present.

The bill does not ban the possession of tobacco products, just their use. Enforcement is also left up to individual school boards. School boards have also been given three years to opt out of the ban.


As of July 2018, only 42 percent of the Kentucky's 173 school districts have 100% tobacco free school policies, covering 57% of the state's students, and many of them have not updated their policy to meet new standards for electronic cigarettes.

"Up to 225,000 more Kentucky students will be protected from secondhand cigarette smoke and e-cigarette aerosol at school thanks to the tobacco-free schools bill," Bonnie Hackbarth, vice-president of external affairs for the Foundation for a Healthy Kentucky, said in a news release.

Moser said it took "many voices' to get this "positive piece of legislation" passed, and expressed her gratitude for them all. "I'm just excited for Kentucky," she said. "Looking forward, I think every step we take toward improving our health is a good step for Kentucky."

CDC says ground beef likely source of E. coli outbreak, but hasn't been able to identify the source; Kentucky has most cases

Centers for Disease Control and Prevention map

Investigation of people stricken by the recent outbreak of E. coli "suggests that ground beef is the source of this outbreak," the Centers for Disease Control and Prevention announced Friday. "At this time, no common supplier, distributor, or brand of ground beef has been identified."

The outbreak, centered in Kentucky, has sickened 109 people and sent 17 to the hospital, the CDC reported. One case was found this week in Indiana, making the sixth state touched by the outbreak. Kentucky has 54 cases, Tennessee 28, Georgia 17, Ohio 7 and Virginia 2.

The agency said it is continuing its probe "to determine the source of ground beef supplied to grocery stores and restaurant locations where ill people ate. At this time, CDC is not recommending that consumers avoid eating ground beef or retailers stop serving or selling ground beef."

However, the agency cautioned, "Raw ground beef should be handled safely and cooked thoroughly to kill germs that could cause foodborne illness." It offered detailed advice: to consumers, retailers, and restaurants:

• Consumers should cook ground beef to an internal temperature of 160˚F.
• Wash hands with soap and water after touching raw ground beef.
• Keep raw meat separate from foods that won’t be cooked before eating.
• Thoroughly wash countertops, cutting boards, plates, and utensils with hot, soapy water or a bleach solution after they touch raw meat.
• Don’t eat raw or undercooked ground beef.
• After cooking ground beef, refrigerate within two hours and use within three to four days.
• Thaw ground beef in the refrigerator. Cook or refreeze within two days.
• Talk to your doctor if you have symptoms of an E. coli infection.

Escherichia coli is a common bacterium found in the digestive tracts of mammals. Certain strains, such as the one numbered O103, which is identified with this outbreak, can produce Shiga toxin, which causes diarrhea (often bloody), severe stomach cramps, and vomiting.

"Most people recover within a week, but some illnesses can last longer and be more severe," the CDC says. "Antibiotics are not recommended for patients with suspected E. coli infections until diagnostic testing can be performed and E. coli infection is ruled out." More information is at https://www.cdc.gov/ecoli/ecoli-prevention.html.

Kentucky judges and court staff will be offered opportunities to learn more about addiction, recovery and treatment

By Melissa Patrick
Kentucky Health News

Kentucky will soon offer an educational program to its judges and court staff that will provide "trauma-informed, evidence based content" around the issues of opioid- and substance-use disorders, treatment and recovery as a way to help them make informed decisions in cases that involve substance-use disorders.

Chief Justice John D. Minton Jr.
(Photo by Melissa Patrick)

The program is called RESTORE, for "Responsive Education to Support Treatment in Opioid Recovery Efforts." It is part of the Kentucky Opioid Response Effort, or KORE, which is funded by a $10.5 million federal grant. 

"We want to prepare our court officials to make decisions that support recovery rather than to hinder it," Chief Justice John D. Minton Jr. said as he announced the program in the state Supreme Court chamber. "Our vision for RESTORE is that we will gain a shared understanding of substance use disorders and embrace best court practices in courts in dealing with this disease all across the commonwealth."

State Justice and Public Safety Secretary John Tilley alluded to the need for this education in March when he told a room full of visiting Fulbright scholars at the University of Kentucky that Kentuckians with addictions are treated differently across the state when arrested, depending on judges' understanding of addiction and the availability of wrap-around services to help offenders.

"It's incredibly disparate, and it's unjust," Tilley said at UK. "It is injustice at its best." He was unable to attend the launch of the program because of scheduling issues.

The program does not offer a required course of action for the judges to follow for such offenders, but to laughter in the room full of judges, Family Court Judge Janie McKenzie-Wells of the 24th Judicial Circuit said, "When the chief makes a suggestion, we usually take it."

She then added, "Obviously you have to buy in to this program and part of the educational piece . . . is to sell what we are doing to the judges and staff."

The program will consist of two one-day summits in each of Kentucky's seven appellate-court districts. The summer session is titled "Understanding Opioid and Substance Use Disorder;" the fall session is titled, "Understanding Treatment and Recovery."

Minton said the justice system offers a unique opportunity to help people with substance-use disorders.

"The decisions made at each point of contact within the justice system can profoundly affect the recovery process of each adult, youth and family who interacts with the courts," he said. "We have a duty to understand what research puts forth as the most effective court processes, the most effective practices, interventions and treatment models that can support lifelong recovery."

Wendy Morris, commissioner of the state Department for Behavioral Health, Development and Intellectual Disabilities, which oversees KORE, said Kentucky's collaboration across departments on this issue is unique.

As examples, she pointed to the Department of Public Health's commitment to harm reduction, the Department of Community Based Services' work with families who are affected by substance abuse, Medicaid's robust array of treatment options, judges who volunteer their time in drug and family courts, and their own work to oversee it all. She added that the involvement of the criminal justice system will provide yet another opportunity for intervention with this population.

Van Ingram, executive director of the Kentucky Office of Drug Control Policy, said the state's collaborative efforts against what he called "the worst drug epidemic our country has ever seen" are paying off.

Ticking off a long list of things the state is doing to combat this epidemic, Ingram said the numbers show that we are headed in the right direction, with fewer emergency-room overdose deaths and fewer hospitalizations in 2018 than the prior year, and an upcoming report that will show for the first time in 15 years, overdose deaths in Kentucky are declining.

"It's been a long fight, but we are beginning to see some progress," said Ingram. "And it's really because of these kinds of collaborations."

McKenzie-Wells talked at length about the Johnson County Community of Hope, a program that works in Family Court to address a whole array of issues commonly faced by people with substance-use disorders, whether that be access to housing or as is often the case, the need for a gas card to get them where they need to go.

She reminded everyone that whether you know a person with a substance-use disorder personally or not, these are people who live in our communities and need our help. "This is a community problem, so let's work on the solution as a community," she said. "And I think that's what RESTORE is aimed at."

Kentucky leads the nation in child abuse, which in most cases is neglect that equals abuse; April is Child Abuse Awareness Month

From an editorial by The Winchester Sun

Kentucky ranks first in the nation in a terrible way, according to a recent report.

The most recent Child Maltreatment Report, issued in late March by the the Children’s Bureau of the U.S. Department of Health and Human Services, reveals Kentucky has the nation's highest rate of child abuse, which includes child neglect.

According to the report, Kentucky had 22,410 child-abuse victims in 2017, the last year for which data is available. That equates to a rate of about 22 victims per 1,000 children in the commonwealth, which is more than twice the national average rate of nine. Ten child fatalities were attributed to abuse in Kentucky in 2017.

Kentucky’s child-abuse rate has increased annually from 2013, when it was 17.3 per 1,000. That's an increase of more than 27 percent over the four-year period. Among the victims in 2017, more than 15,000 were first-time victims, meaning more than 7,000 children had been abuses in previous years.

Most of the the 22,410 cases (21,313) in 2017 were attributed to neglect. There were 487 cases of medical neglect, 1,533 cases of physical abuse, 44 cases of psychological maltreatment and 852 cases of sexual abuse. Many involved more than one of these serious issues.

More than 3,000 of Kentucky’s cases of child abuse involved alcohol abuse by their caretaker and nearly 12,000 involved drug abuse. Also, according to the report:

• Nationally, evidence indicates children are most likely to be abused by their parents
• Children in their first year of life have the highest rate of victimization at 25.3 per 1,000 children of the same age in the national population. In Kentucky, 3,090 cases were reported in children younger than 1 year in 2017.
• “Child fatalities are the most tragic consequence of maltreatment,” according to the report. “For 2017, 50 states reported 1,688 fatalities.”

While many die each year, and others are treated, there are likely thousands more cases in our state where the abuse goes unreported. These children survive, but are destined to deal with the negative ramifications of their childhood abuse for the rest of their lives — often prohibiting them from becoming well-functioning, healthy, productive adult citizens.

April is Child Abuse Awareness Month, a time dedicated to honoring and remembering the lives lost too soon to abuse and neglect. The month also serves as an opportunity for the community to band together to raise awareness, educate about risk factors and indicators and advocate for children.

It’s a problem that has no easy solution, but one that must be addressed from multiple angles and quickly. We can all take part in reversing this negative trend and helping survivors. The most important things we can do are advocate and educate. Learn about the indicators of abuse. There are many, including unexplained bruises, cuts, welts, scars, fractures and burns.

There are also behavioral indicators, like aggressiveness or withdrawal. Other obvious signs are children who are frightened of their parents or say they are afraid to go home. Be mindful of children who report being extremely hungry, who exhibit bad hygiene or dress inappropriately for the season.

Watch for children in your community who are often unsupervised, especially for long periods of time or in potentially dangerous scenarios. Report potential abuse to the police or by calling the Child Help National Child Abuse Hotline at 1-800-4ACHILD.

Encourage your legislators to support laws that protect children and strengthen punishments for abusers. Additionally, our state must continue fighting against addiction, including drugs and alcohol. They play a huge role in the quality of life for our families and children, and as this research indicates, contribute to child abuse and neglect in our state.

Our state needs to also allot more funding for the Department for Community Based Services and other child-welfare programs. There are shortages of qualified social workers and foster parents to help these children find their way out of abusive homes and into loving, safe places.

Finally, we need to improve access and funding for programs for parents, including parenting classes, HANDS programs, educational programs and other assistance programs to reduce the burden of stress many parents, especially first-time, young or low-income parents feel, which might result in abuse or neglect.

Childhood should be fun. It should be a time of growth and learning. It’s a time to be nurtured and loved. Our children are our future and they deserve better.

Be mindful. Speak up. Stop abuse. Report it. Be an advocate. Help make the world a better place for children.

McConnell attacks 'Medicare for All,' says he favors 'niche fixes'

Bret Baier of Fox News interviews U.S. Sen. Mitch McConnell.

Senate Majority Leader McConnell told Fox News April 10 that he favors “niche fixes” for health care, while vowing that next year's elections will include a debate “about whether we want to turn America into a socialist country.”

The day before, McConnell targeted "Medicare for all" and other health plans of Democrats at the annual meeting of the American Hospital Association, and the group's leader endorsed more modest changes to the 2010 Patient Protection and Affordable Care Act.

"The hospital lobby already opposes Medicare for All and says bolstering the exchanges and getting more states to expand Medicaid is a better path toward universal coverage," Chelsea Cirruzzo and Michelle Stein of Inside Health Policy report. "McConnell told the group that his health-care plan is 'keeping what works and fixing what doesn’t,' but he didn’t elaborate as he targeted Medicare for All as the wrong solution."

McConnell said hospitals "should not be the guinea pigs in some far-left social experiment," which would cost $32 trillion over 10 years by shifting most health-care costs to the government. "He similarly blasted other health care proposals being considered by Democrats, naming the public option and Medicare buy-in, which he said would take the power from patients and give it to the government."

Asked the next day by Bret Baier of Fox what the Republican plan is for health care, McConnell said, “Look, we made that effort last Congress, it didn’t work. Clearly the Democratic House is not going to pass it. So we’re not going to spend time in the Senate on things that have literally no chance of becoming law.”

AHA President and CEO Rick Pollack "suggested improvements to the Affordable Care Act as a better way to expand coverage," including expanding Medicaid in Republican-dominated states that have not expanded it, and giving them the same deal that Kentucky and most other states took: full federal funding for the first three years, then declining to 90 percent over four years.

Pollack also called for “restoring cost-sharing subsidies for low-income consumers and implementing well-designed reinsurance mechanisms” to protect insurance companies who may get stuck with disproportionately ill policyholders. "He also said an alternative should include bigger subsidies for low-income individuals who want to purchase exchange coverage and adequate funding for enrollment efforts," Cirruzzo and Stein report.

Trump administration appeals rulings that blocked Medicaid work rules in Ky. and Ark.; decision not likely until after Nov. 5 election

As expected, the Trump administration has appealed a decisions by a federal judge in Washington, D.C., that stopped Kentucky and Arkansas from requiring some people on Medicaid to work.

The Centers for Medicare and Medicaid Services appealed April 10 to the U.S. Court of Appeals for the District of Columbia Circuit, "which often has the final say on the legality of controversial regulatory policies," reports James Romoser of Inside Health Policy. Gov. Matt Bevin has said the issue will be decided by the U.S. Supreme Court, which could refuse to hear a further appeal.

U.S. District Judge James Boasberg

District Judge James Boasberg "ruled that CMS failed to show how the waivers would promote Medicaid’s central purpose of providing people with medical coverage," Romoser notes. "Boasberg’s rulings sent the waivers back to CMS for further review, meaning CMS had the option to re-evaluate or modify the waivers in hopes of satisfying Boasberg’s concerns. But the agency indicated in court papers last week that, rather than take any further action on the waivers right now, it intended to bring the case to the D.C. Circuit and seek to have Boasberg’s rulings overturned."

Appeals in federal courts are randomly assigned to three-judge panels. "It is not clear whether a single panel will oversee both the Arkansas and Kentucky cases," Romoser writes. "Among the D.C. Circuit’s 11 full-time judges, seven were appointed by Democratic presidents and four were appointed by Republican presidents. The court also has six senior judges, who handle a reduced caseload. Five of them are Republican appointees and one is a Democratic appointee."

The cases are likely to spend several months at the D.C. Circuit, probably beyond the Nov. 5 election, in which Bevin is highly likely to be the Republican nominee for another four-year term. Kentucky officials have intervened in the case and have said they will participate in the appeal. The Kentucky case is Stewart v. Azar, No. 1:18-cv-152.

The Trump administration is "expected to argue that Boasberg, an Obama appointee, failed to provide enough leeway to HHS Secretary Alex Azar to test new policies that he believes will serve Medicaid’s goals," Romoser writes.

UPDATE: In a statement, state Health Secretary Adam Meier voiced confidence that Boasberg would be found wrong, and that his worst mistake was his "unprecedented conclusion that Medicaid does not care about improving people’s health." That was a reference to the following passage in Boasberg's ruling (emphasis added):

"Rather than adequately addressing Kentucky HEALTH’s potential to cause loss of medical coverage, the Secretary continues to press his contention that the program promotes his alternative proposed objectives of beneficiary health, financial independence, and the fiscal sustainability of Medicaid. The Court finds that the first two of those three goals are not objectives of the [Medicaid] Act in their own right, and, regardless, the Secretary’s failure once again to adequately consider the effects of Kentucky HEALTH on coverage is alone — as it was in [the initial case] — fatal to the approval."

The state and federal governments argued that the objectives of Medicaid for the 450,000 people in the expansion differed from those of traditional Medicaid, and that the new plan would improve their health. Boasberg rejected that argument both times. In the latest ruling, he wrote, “The Secretary’s primary contention is that health must be an independent objective because there is little value in paying for health care if it is not advancing that goal. As the Court explained in its prior opinion, health was not necessarily the ultimate aim Congress pursued when it decided to 'provide health insurance to needy populations.' . . . Congress thus designed a scheme to address not health generally, but the provision of care to needy populations. The Secretary is not free instead to extrapolate the objectives of the statute to a higher level of generality and pursue that aim in the way he prefers.”