McConnell files bill to raise legal age to buy tobacco products to 21, with some provisions Kentucky health advocates wanted

By Melissa Patrick and Al Cross
Kentucky Health News

Senate Majority Leader Mitch McConnell today introduced his promised bill to raise to 21 from 18 the legal age to buy tobacco products in the United States, in response to what he called a public-health epidemic of electronic-cigarette use by teenagers.

Senate Majority Leader Mitch McConnell talks tobacco.

"Youth vaping is a public health crisis," McConnell said during a floor speech to introduce the bill. "It's our responsibility as parents and public servants to do everything we can to keep these harmful products out of high schools and out of youth culture. We need to put the national age of purchase at 21."

Most adults who smoke start before they turn 21, so increasing the tobacco age to 21 will keep youth from starting, save lives and improve public health, says the Institute of Medicine. McConnell said he would make enacting the bill one of his highest priorities.

McConnell's co-sponsor is Sen. Tim Kaine, D-Va. "As senators from two states with a long history of tobacco production and consumption, [they] have seen this phenomenon firsthand, and heard the compelling stories from concerned constituents throughout their states," said a short explanation of the bill and the reasons for it. The bill is called the Tobacco-Free Youth Act.

McConnell gave a detailed history of how tobacco helped shape the nation and Kentucky. He said the state had almost 30,000 tobacco farmers when he helped end the federal tobacco program in 2004, but now has only 2,600.

"For many in Kentucky, tobacco made the American dream possible," he said, but also talked about the negative impact tobacco has had on Kentuckians' health. The state leads the nation in cancer and the percentage of cancers tied directly to smoking. "Our state once grew tobacco like none other — and now we’re being hit by the health consequences of tobacco use like none other," he said. "We’re proud of our past, we’re proud of who we are, but Kentucky farmers don’t want their children to get hooked on tobacco products while they’re in middle school or high school anymore than any parent anywhere wants that to happen. . . . The health of our children, literally, is at stake.”

According to the Kentucky Incentives for Prevention survey, teen use of electronic cigarettes in Kentucky nearly doubled from 2016 to 2018. The survey found that 26.7% of the state's high-school seniors reported using e-cigarettes in the 30 days before they were surveyed in 2018, up from 12.2% in 2016. Among 10th graders, it increased to 23.2% from 11.3%; eighth graders jumped to 14.2% from 7.3%; and sixth-grader use increased to 4.2% from 2.3%.

McConnell pointed to a nationwide survey that found the use of tobacco products increased by nearly 40% between 2017 and 2018, driven almost entirely by vaping. "The brain is still developing at this young age. When teenagers use tobacco, they're quite literally altering their brain chemistry and making it more susceptible to addiction," he said.

Enforcement is up to the states

Federal law does not establish a penalty for violating the current age limit of 18, but leaves enforcement up to the states and makes certain federal grants dependent upon enforcement.The McConnell-Kaine bill would leave that system in place. Laws in Kentucky and many other states have penalties for under-age youth who buy, possess or use tobacco products.

Advocates will have to work with state legislators to remove those laws, said Bonnie Hackbarth, vice president for communications at the Foundation for a Healthy Kentucky, which has endorsed McConnell's bill.

"Our interest was to make sure that there was nothing in the federal bill to impose penalties on the actual purchaser, but to rather put those penalties on the retailers where they should be and that is the way the bill is written," Hackbarth said. "That would be our goal, that the penalties would be on retailers and not the purchasers."

Foundation President and CEO Ben Chandler said in a news release, “Since Sen. McConnell stood in our offices just last month and announced plans to file this bill, new data has come out showing that youth e-cigarette use in Kentucky doubled over the past two years. We’re gratified that the provisions we sought to help reduce this explosion in youth vaping and other tobacco use have been included in the bill: It covers all tobacco products, including e-cigarettes as well as heated products; it prohibits sales to everyone under age 21, with no military exemption; it puts responsibility for compliance where it should be – on retailers, and it preserves the right of states to enact stricter laws.”

Chandler added, “We urge Congress to pass this bipartisan bill quickly and states to begin getting their own T21 bills in order. Every extra day it takes to put this important legislation into effect is an opportunity for thousands more kids to access a tobacco product that can damage their developing brains now and cause debilitating health issues throughout their lives.”

The bill has already received the support of several organizations, but others are being more cautious before they give it their approval.

"Increasing the minimum sale age for all tobacco products to 21 offers a common-sense way to keep harmful tobacco products out of reach of our kids and prevent life-long addictions to nicotine," Dr. Terry Brooks, executive director of Kentucky Youth Advocates, said in a release. "We urge Congress to support this bipartisan bill and for our leaders in Frankfort to begin work aligning state law to protect more youth from the lasting harms of tobacco use."

Some advocates want more

The American Lung Association also supports the bill, though it calls for more action, including a ban on flavored tobacco products, restricting online sales of the products and increasing funding for the Centers for Disease Control and Prevention's Office on Smoking and Health.

The Campaign for Tobacco-Free Kids said it was still evaluating the bill to make sure it is strong enough, including strong enforcement penalties on retailers, no exemptions and no "special interest provisions that block other policies needed to protect kids and public health, such as prohibitions on flavored tobacco products."

With the support of McConnell and Kaine, the bill is expected to have little trouble in the Senate, but its House prospects "are unclear," The Wall Street Journal reports. "House Democratic aides said they are still reviewing it, though they pointed to more expansive legislation introduced in the House that would also restrict flavored e-cigarettes and regulate marketing to young people, among other measures, in addition to raising the age for purchasing tobacco. Legislation that takes similar measures—but doesn’t raise the purchasing age—has received bipartisan support in the Senate."

McConnell's bill addresses some of the advocates' concerns. It does not exempt people in the military, as he originally said it would, and it would allow states to pass stronger tobacco laws.

McConnell told Deborah Yetter of the Louisville Courier Journal that he was aware of health advocates' concerns that tobacco companies support the legislation only because it could shield them from more aggressive enforcement and a possible ban on flavorings.

"Just the fact that they're for it doesn't mean it's a bad idea," he said. "This is just a floor, not a ceiling. I don't think it relieves them of any of the battles they're going to have to fight at the state and local levels in the future."

A bill to raise the legal age to buy tobacco products in Kentucky failed in the last session of the legislature, after opponents said it would hurt the tobacco industry. The bill, and similar legislation passed in Virginia and 13 other states, is backed by Virginia-based Altria Group, the nation's largest cigarette maker. Altria recently bought 35% of Juul Labs, maker of the most popular e-cigarette.

Study suggests kids with hypertension more likely to have heart disease as adults; Ky. teens 3rd in U.S. in top risk factor, obesity

Parents.com photo

By Melissa Patrick
Kentucky Health News

Just like adults, children can have high blood pressure. The only way to know is to check for it, and it's important because children with hypertension are more likely to grow up to be adults with heart disease -- the number one killer of adults in Kentucky. And in the biggest risk factor for heart disease, obesity, Kentucky high-school students are the third most likely in the U.S. to be obese.

"Children don't have a lot of symptoms with high blood pressure, so we don't know they have it until we check," said Dr. Donna Grigsby, chief of general pediatrics at UK HealthCare. " If they don't get it under control when they are young it's likely to persist into adulthood. . . . There are a lot of long-lasting consequences to living with high blood pressure that is not well-managed."

Untreated hypertension in adults can lead to heart disease, heart failure, vision loss, stroke and kidney disease.

Grigsby noted that the American Academy of Pediatrics issued new blood-pressure guidelines for children in 2017, and that diagnosing hypertension in children is a little trickier than diagnosing it in adults because it varies by a child's age, height and gender. She stressed that health-care providers have to do more than just take a child's blood pressure; they also have to interpret it.

A recent study in the American Heart Association journal Hypertension suggests kids with hypertension are at a higher risk of heart disease as adults.

Using data from nearly 4,000 children who were followed for 36 years, the study found that the newer guidelines classified 11% of children as having hypertension; the old guidelines classified 7%.

It also found that 19% of the children with high blood pressure according to the new guidelines had an enlarged heart (left ventricular hypertrophy, or LVH) as adults. Under the old guidelines, it was only 12%.

Sperling's Best Places map

A possible pitfall in the study was that all of the children in this study come from one community: Bogalusa, Louisiana, just across the Pearl River from Mississippi, a town of 12,000 with a 57% white and 41% population. Also, the study used no information about actual heart attacks and stroke.

Overall, the study found that 8% of the children who were reclassified to having high blood pressure under the new guidelines were more likely than those without hypertension to develop heart disease as adults; and the children who were reclassified to the lower blood-pressure categories with the new guidelines had similar results as those who had never been diagnosed with hypertension.

"Children who were reclassified to higher blood pressure categories based on 2017 guidelines were at increased risk of hypertension, metabolic syndrome and LVH in later life," the report says.

Metabolic syndrome is a group of risk factors that raises a person's risk for heart disease, stroke and diabetes. They include high blood pressure, excess fat around the waist, high blood-sugar levels, high triglyceride levels and low levels of good cholesterol, or HDL. Having any three of these risk factors produces a diagnosis of metabolic syndrome.

Grigsby said all children should start having their blood pressure checked at age 3, and children who are considered at higher risk of developing high blood pressure should have it done sooner, including those who were born prematurely or who have kidney or heart disease.

The Centers for Disease Control and Prevention reports that an estimated 1.3 million youth between the ages of 12 and 19 have hypertension under the new guidelines, which is about 4% of the population. For example, the CDC says that in a classroom of 30, one would have high blood pressure and about three more would have "elevated blood pressure," once called "prehypertension."

Kentucky-specific data were not available, but the primary risk factor for high blood pressure in children is obesity, and that's a real problem in Kentucky. According to the State of Obesity report, one in five, or 20.2%, of the state's high-school students are obese, the third highest in the country.

"The children that we worry about are the children who are overweight and obese because we know that is a big risk factor for having high blood pressure," Grigsby said.

She said high blood pressure in children is primarily treated with lifestyle changes, like decreasing screen time, increasing activity, and improving diets -- and these changes are most successful when the whole family makes them.

"Instead of diet and weight loss, we talk a lot about healthy lifestyles because this is a change that they are going to have to be able to sustain," she said.

The Kentucky Department for Public Health suggests the 5-2-1-0 prescription to significantly reduce childhood obesity, which says to eat five or more servings of fruits and vegetables each day; limit screen time to no more than two hours a day; be physically active for at least one hour a day; and drink zero sweetened beverages. The website offers free resources to help meet these goals.

Most Ky. hospitals got an average patient safety score, one failed; low scoring hospitals have increased risk of "avoidable death"

By Melissa Patrick
Kentucky Health News

For the second grading period in a row, a nonprofit group that rates hospitals has given Cs to most of the 52 Kentucky hospitals it rated; and for the first time since 2015, one hospital got an F, along with only nine other hospitals nationwide. In the percentage of hospitals with A grades, Kentucky continues to rank 33rd among the states.

The Leapfrog Group, a nonprofit group based in Washington, D.C., rated more than 2,600 hospitals. Most of Kentucky's 129 hospitals were not rated, since rural hospitals with "critical access" status don't have to report quality measures to the federal government.

Leapfrog gave As to 11 Kentucky hospitals, or nearly 21% of those graded, lower than the national average of 32%. It gave Bs to 10, Cs to 25 , Ds to 5 and an F to 1. With the exception of the one failing grade, these numbers are similar to the fall report.

Methodist Hospital of Henderson was one of only nine hospitals nationwide that got a failing grade, putting it in the bottom 1% of hospitals scored. Leapfrog shows that the hospital's score has dropped steadily since the spring of 2016 when it got an A; that was followed by two Bs, two Cs, a D and an F.

The twice-yearly grades are calculated using 28 performance measures of patient safety that indicate how well hospitals protect patients from preventable medical errors, accidents, infections and injuries. The report uses data from the Centers for Medicare and Medicaid Services, Leapfrog's own survey, and other supplemental data sources. Hospitals are only graded if they have submitted adequate data for evaluation.

The Leapfrog Group Hospital Safety Grade website is easy to use and offers
information on 52 Kentucky hospitals.

The Leapfrog site offers details on each of the measures under headings titled infections, problems with surgery, practices to prevent errors, safety problems, doctors, nurses & hospital staff. It also includes an easy-to-read, color-coded scale that indicates how the hospital is performing.

For example, Methodist Hospital of Henderson scored below average on 16 of the measures, average on one measure, and above average on nine; and two measures weren't evaluated.

Only two other Kentucky hospitals have ever received a failing grade from Leapfrog: Saint Joseph East in Lexington in fall 2015 and Taylor Regional Hospital in Campbellsville in the spring 2013.

According to the Leapfrog researchers, hospitals with grades lower than an A can put patients at an increased risk of "avoidable death." The news release says patients at D and F hospitals face a 92% greater risk of avoidable death; patients at C hospitals on average face an 88% greater risk of avoidable death; and patients at B hospitals on average face a 35% greater risk of avoidable death.

Leapfrog estimates that 160,000 lives are lost every year from avoidable medical errors that are accounted for in its grading process. It says that's a significant improvement from 2016, when it estimated the number to be around 205,000.

“The good news is that tens of thousands of lives have been saved because of progress on patient safety,” Leah Binder, president and CEO of the Leapfrog Group, said in the release. “The bad news is that there’s still a lot of needless death and harm in American hospitals.”

High scorers

St. Elizabeth Healthcare-Edgewood has received As on every Leapfrog report card since spring 2014, the first year it was graded.

Other hospitals on the A list are: St. Elizabeth hospitals in Florence and Fort Thomas; Baptist Health Lexington; Clark Regional Medical Center in Winchester; Georgetown Community Hospital; Harrison Memorial Hospital in Cynthiana; Norton Audubon Hospital, Norton Brownsboro Hospital and Norton Women's & Children Hospital, all in Louisville; and Whitesburg ARH Hospital.

Norton Brownsboro and Norton Women's & Children hospitals were the the only two on this list to change their status since the last grading period, both moving up from a B.

Low scorers

The five hospitals that got Ds are: Taylor Regional Hospital, Hazard ARH Regional Medical Center; Highlands Regional Medical Center in Prestonsburg; Jewish Hospital in Louisville; and the University of Louisville Hospital.

This was the first D assigned to the Hazard hospital, which since the spring of 2016 had received Bs and Cs. Taylor also moved from a C to a D.

Jewish and the U of L hospital have received Ds since the spring 2016.

U of L Hospital, which separated from KentuckyOne Health on July 1, 2018; KentuckyOne Health, which owns Jewish and Sts. Mary & Elizabeth Hospital; and Baptist Health, on behalf of several of its hospitals across the state, sent statements to Darla Carter of Insider Louisville saying they took issue with the grades, namely because they are based on older data.

“We have reviewed our (publicly) reported data since July 2017, and utilizing the Leapfrog Group’s own calculator for scoring with that data, our calculated grade would have been a C,” Dr. Jason Smith, chief medical officer of U of L Hospital, told Insider Louisville. “This improvement is in line with what we anticipated our ranking would be at this point when we re-assumed oversight of our hospital in July 2017.”

Shifts up and down

TriStar Greenview Regional Hospital in Bowling Green dropped to a grade of B, after receiving five As in a row.

Others on the B list include: Baptist Health Paducah, which maintained its B from the last grading period after getting four Cs in a row; Frankfort Regional Medical Center, which maintained its B from the last period after receiving five As in a row; and Mercy Health Lourdes in Paducah, which maintained its B from last time after getting two Ds and three Cs. The two University of Kentucky hospitals got Cs for the second straight grading period, after getting four Bs in a row.

Three hospitals on the C list dropped from a B in the last grading period: Jackson Purchase Medical Center in Mayfield, Harlan ARH Hospital and T. J. Samson Community Hospital in Glasgow. Saints Mary & Elizabeth Hospital in Louisville got its second C in a row, after having received a D grades since spring 2016.

The Leapfrog Group says its analysis was developed under the guidance of the nation's leading patient-safety experts and is peer-reviewed. Click here to see all of Kentucky hospital's Leapfrog hospital safety grades. Click here for Leapfrog recommendations on how to use the grades.

Infection-control activist calls for timely outbreak notifications, comprehensive tracking, aggressive containment and vaccines

OPINION By Dr. Kevin Kavanagh

I live in Kentucky, a state with the nation’s largest hepatitis A outbreak, an emerging measles outbreak and a governor who said he exposed his children to chickenpox rather than get them vaccinated. In the past year, two heads of infection control in Kentucky’s Department of Health have left the position. The first one was asked to leave after he expressed the need for an urgent increase in infection control funding.

Dr. Kevin Kavanagh

I am a firm believer that we must learn from history or be doomed to repeat it. Unfortunately, the United States and many other nations appear not to have learned this lesson with regard to public health and are heading down a dangerous path.

The recent book The Pandemic Century by Mark Honigsbaum examines a number of major disease outbreaks around the world and draws lessons about how some of them were mismanaged. But one can see many disturbing parallels in the handling of today’s epidemic of drug-resistant bacteria and viruses.

One of the most important is that when infections spiral out of control, governments worry too much about avoiding accountability, often downplaying the severity of an outbreak until it is too late. In the severe acute respiratory syndrome epidemic of 2002 and 2003, for example, the Chinese government initially withheld information about an outbreak in Guangzhou, which delayed the discovery that the infection was not caused by the flu, but by a more dangerous pathogen.

In the ebola epidemic of 2014, the government of Guinea, a country with very limited health resources, initially insisted that only laboratory-confirmed cases be counted, this led to a drop in reported cases and a false sense of security, delaying the mobilization of resources and fueling the spread of the virus.

And as the 2015 Zika epidemic was taking hold, resulting in the births of babies with the neurological condition microcephaly, the Brazilian Ministry of Health changed the definition of microcephaly from a head circumference of 33 centimeters to 32 centimeters, effectively reducing the numbers of cases.

The United States also falls victim to the practice of mathematical case reduction. Several years ago the Centers for Disease Control and Prevention doubled the amount of bacteria required to be present before a urinary infection must be reported to health officials. Bladder infections associated with a catheter and caused by any type of yeast are no longer reported, which technically includes the deadly superbug Candida auris.

The definition of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections has been changed from patients who developed an infection after two days of hospitalization to after three days. And the number of “community-acquired” infections occurring in the first three days of hospitalizations are not released to the public.

And instead of fixing a requirement that hospitals keep logs of infectious disease cases, in 2012 the U.S. eliminated this requirement and used our current spotty federal tracking system as justification.

In past epidemics, the cause and mechanism of the spread of infection and even vaccines were desperately sought after, but academic pride and competition often impeded science. No better example was the Spanish flu epidemic, which killed more soldiers in World War I than the war itself. Academic pride perpetuated the myth that the primary cause was a bacteria and not a virus. In the past few decades, other powerful factors, industrial profits and conflicts of interest, have emerged.

Finally, local beliefs, lack of education and mistrust create the breeding ground for pandemics. This was evident in the 2014 ebola outbreak, when the general population believed that the infection was a government plot and that health-care workers were purposely spreading the infection. In addition, they firmly embraced social customs and burial practices that were fueling the epidemic.

In some respects, this type of misinformation and paranoia is held by many who refuse to vaccinate their children. Often standing behind a shield of “religious freedom” or “personal belief,” such parents are allowing their children to act as reservoirs to spread dangerous pathogens. I have a niece who had a heart transplant and is immuno-compromised, and it terrifies me that the anti-vaxxers could jeopardize her life.

Americans over 65 still remember the ravages of epidemics and how vaccines were transformative. I still vividly recall being deathly sick with measles as a young child. I would not wish this on anyone. When the vaccines came out, there was a public rush to get them, and we all stood in long lines. But as memories faded, a suspicion of vaccines grew and dangerous pathogens re-emerged.

The public needs timely notification of infectious disease outbreaks, and epidemics need to be comprehensively tracked and aggressively confronted. All states should mandate vaccinations and eliminate religious exemptions. Our collective health depends on having public policy fully aligned with good science.

Physician Kevin Kavanagh of Somerset is founder and chairman of Health Watch USA, a nonprofit patient-advocacy and health-care policy research organization. Kavanagh wrote this opinion piece for the Los Angeles Times.

Hepatitis outbreak is declining in Ky., but we are still finding more in a week than we once got in a year; 57 have died from it in state

The good news about hepatitis in Kentucky is that the number of hepatitis A cases is dropping. The bad news is that there are still as many cases each week as were once seen in a year's time, and the state is by the far the leader in deaths from the liver disease.

According to the state's weekly report, the number of hepatitis A cases in Kentucky has dropped to around 20 per week for several weeks, a huge improvement from the height of the outbreak in the last months of 2018, when more than 100 new cases were being reported every week. But before the outbreak, which was declared in November 2017, the state averaged about 20 cases a year.

Since August 2017, the report shows that 4,621 Kentuckians have been diagnosed with hepatitis A and 2,233, or 48% of them, have been hospitalized. The primary risk factors for getting this highly contagious disease remains illicit drug use and homelessness.

The 57 deaths reported in Kentucky account for about one-third of the 170 deaths reported to the Centers for Disease Control and Prevention since 2016 in 22 states. "West Virginia and California, by comparison, each has had 21 deaths in their outbreaks. Michigan has had 28, and Indiana 4," Chris Kenning reports for the Louisville Courier Journal.

Four Kentuckians died from the disease in the week ending May 4, says the latest state report. It notes that deaths are identified through periodic reviews of death records and includes anyone who dies with documentation of hepatitis A as a contributing factor to the death -- even if it wasn't the primary cause of death, which is often the case among drug users.

Hepatitis A has been diagnosed in 108 of the state's 120 counties, with 15 reporting new cases in the week ending May 4.

The state's initial response to the outbreak has been criticized for not being aggressive enough.

Kenning notes that a Courier Journal investigation found that the state's former infectious-diseases chief, Dr. Robert Brawley, "recommended $6 million for vaccines and $4 million for temporary workers to help thinly staffed local health departments deliver vaccines to hard-to-reach drug users. He also called for a public health emergency declaration to help pave the way for federal assistance. Instead, Department for Public Health Commissioner Dr. Jeffrey Howard, citing limited funding and the local reserves that some health departments had, sent $2.2 million in state funds to local health departments and declined to seek an emergency declaration."

Howard and other state officials have defended their actions, citing that logistical challenges were greater than a need for more money as the outbreak spread to rural Kentucky.

Brawley, who was allowed to resign in lieu of being fired on June 4, 2018, has maintained his position that the state has not acted aggressively enough. (Since Brawley left, the state has fired Dr. John Bennett, who had been the state's infectious-disease manager since last fall.)

"The Kentucky public should be outraged about the slow-motion public health response that has caused the hepatitis A outbreak to continue into 2019," Brawley told Kenning on May 14. "I am saddened that 57 Kentuckians have died after developing acute hepatitis A and where hepatitis A was a risk factor for their deaths."

In late March, a legislative measure directing the state to review its response to Kentucky's outbreak failed to pass. The Cabinet for Health and Family Services has said it plans to review its response.

Meanwhile, the state has hired a roving team of nurses to administer vaccines in rural county jails and the state is providing more vaccine storage equipment, money and expertise to a handful of currently hard-hit counties, Kenning reports.

Specifically, Kenning reports that the Pulaski County Jail has been vaccinating its jailers, and that the state health department has awarded $46,000 to Jessamine, Bell and Christian counties, which had requested extra support; and that a roving team of nurses will soon be in the Lake Cumberland area.

"The department is continuing to coordinate with local health officials to ensure that resources are available and prevention efforts continue," Howard said in a statement to the Courier Journal on Tuesday. "We want to reiterate that though cases are declining, this is not a time to be complacent. Rather, we must continue to promote prevention including appropriate hygiene practices and vaccination."

Brawley said, "While the number of reported cases has fallen in recent weeks, I expect that the Kentucky hepatitis A outbreak will continue for at least six more months and will have a total of more than 5,000 cases before the outbreak is declared over."

UK College of Public Health researchers start the Journal of Appalachian Health, free to all, free to share

Researchers in the College of Public Health at the University of Kentucky have started the Journal of Appalachian Health, an online, peer-reviewed journal, saying their overall objective "is to improve the health status of the population of Appalachia through the rapid dissemination of knowledge of their health problems and evidence-based solutions to them." The journal is available free to all readers, and all users are free to copy and distribute the material in any medium or format; and can remix, transform, and build on the material for any purpose.

"There is knowledge in the pages of Appalachia’s hills," the editors write in the first issue. "This journal is positioned to find and publish those translations. It grows from a need to provide an outlet for scholarship about Appalachia’s health so that knowledge, and occasionally wisdom, is shared with those who care about and are committed to improving the region’s health."

The journal's first article reports that children 7 to 9 years old in parts of Appalachian Ohio are almost five times as likely to be exposed to secondhand smoke as children in the nation, and that parents likely under-report the prevalence of smoking in their homes, based on blood samples taken from 404 children.

The journal is open to essays and commentaries as well as research reports. Jill Crainshaw of the divinity school at Wake Forest University writes about the experiences of students who have taken "a multicultural contexts course that includes a 10-day sojourn in the mountains of North Carolina. . . . The health and well-being of human communities are connected to the health and well-being of the geographic places where people live, work, and play."

Ky. health policy forum Sept. 23 will focus on medical marijuana, a topic that is sure to come up again in the next legislative session

By Melissa Patrick
Kentucky Health News

The Foundation for a Healthy Kentucky's annual policy forum this fall will be dedicated to the topic of medical marijuana in hopes of separating what is fact and what is myth, and to better understand how legalizing it would affect public health and society as a whole in Kentucky.

"It's our judgment that there is a lot of misinformation out there, a lot of confusion about what the facts really are," said Ben Chandler, president and CEO of the foundation. "And we are going to try to shine a light on those facts as best we can."

National Conference of State Legislatures map

The Howard L. Bost Health Policy Forum is sponsored by the foundation in memory of the physician who helped create Medicare and Medicaid, developed the Appalachian Regional Hospital system, improved mental health services in Kentucky and created the vision for the foundation.

It will be held at the Marriott Griffin Gate Resort in Lexington on Monday, Sept. 23. The full agenda and registration for the event will be available soon, a foundation news release said.

The topic is timely. In the last legislative session, Kentucky legislators were able to get a bill  to legalize medical marijuana out of committee for the first time. And though it wasn't called up for a House floor vote late in the session, and key Senate leaders maintained their opposition to it, its sponsors have vowed to try again next session.

"We're going into the interim with this momentum behind us," bill sponsor Rep. Jason Nemes, R-Louisville, told the Lexington Herald-Leader in March. "And we'll be back again next year."

Chandler noted that 34 states have already legalized medical marijuana and that Canada and 10 states have legalized recreational marijuana.

"That tells me that this thing has gained an enormous amount of momentum and whether the opponents of it like it or not, they are going to have to deal with it," Chandler said. "It's important for policy makers to know the pros and cons of the issue. . . . What is truth and what is myth? I think we can all use a dose of that, including myself."

Andrew Freedman will keynote

Chandler told Kentucky Health News that the foundation has no position on the issue. He said in the release, "This forum is not about changing minds for or against legalizing medical marijuana; it's about making sure that the practical public health implications are understood and considered in the policy-making process. The bottom-line goal in any policy decision on this topic ought to be protecting and improving public health."

The forum's keynote speaker will be the former Colorado "marijuana czar," Andrew Freedman. He served for three years as Colorado's first director of cannabis coordination, creating the state's regulatory framework for implementing legalized adult-use and medical marijuana. He is the co-founder of Freedman & Koski, a cannabis consulting firm, and works with states and Canada as they consider or implement marijuana legalization programs. Freedman will talk about the impact of legalizing marijuana on a variety of public-health aspects.

Other speakers will focus on the impact of loosening marijuana restrictions on several at-risk populations, including children, those with mental-health issues and those in the criminal justice system. Speakers will also address its impact on accidents, poisonings, crime, state revenues and costs.

Speakers will also address what kind of provider and public education is needed if medical marijuana is legalized, how the quality and dosage of medical marijuana products can be controlled, in what form medical marijuana products should be made available, and gaps in research about medical marijuana and its impact, among other topics.

Ky. law to ban the most common method of second-trimester abortion struck down; Bevin administration will appeal decision

A federal judge has struck down a 2018 Kentucky law banning the most common method of second-trimester abortion.

The law would prohibit physicians from providing a procedure called dilation and evacuation, or D & E, which is the standard method for abortion care after 14 weeks of pregnancy. It would make it a felony for a physician to perform such a procedure and make the doctor subject to sanctions against his or her medical license. The law was passed to go into effect immediately, but was delayed by a court-order pending the trial.

District Judge Joseph H. McKinley Jr.

U.S. District Judge Joseph McKinley, who heard the case without a jury, "ruled the law is unconstitutional because it restricts a woman's constitutional right to an abortion before the fetus is considered viable, at around 24 weeks," Deborah Yetter reports for the Louisville Courier Journal.

The American Civil Liberties Union, which filed the challenge to the law on behalf of EMW Women's Surgical Center in Louisville, the state's only abortion clinic, said the ruling was a victory for women's health.

“Today’s ruling affirms that health, not politics, will guide important medical decisions about pregnancy," Alexa Kolbi-Molinas, senior staff attorney with the ACLU Reproductive Freedom Project, said in a prepared statement. "Laws like this are part of an orchestrated national strategy by anti-abortion politicians to push abortion out of reach entirely. Today’s decision holds — in no uncertain terms — that Kentuckians and the care they need come first."

The administration of Republican Gov. Matt Bevin, who has made fighting abortion a central issue, said it will appeal.

"We profoundly disagree with the court’s decision and will take this case all the way to the Supreme Court if necessary, to protect unborn children from being dismembered limb by limb while still alive," Elizabeth Kuhn, Bevin's communications director, said in a statement.

"Opponents of the law say it is part of a broader national ploy by the anti-abortion movement to chip away at access to abortions," Yetter reports. "Supporters claim it is meant to end a brutal practice they liken to fetal dismemberment."

Yetter reports that the procedure is used in about 500 of the approximately 3,200 abortions each year at the EMW Women's Surgical Center.

Since Republicans took complete control of Kentucky lawmaking in 2016, the General Assembly has passed several bills to restrict or eliminate abortion in Kentucky. This year, they passed four such bills. Two have been temporarily blocked by a federal judge, one to ban abortion once a fetal heartbeat is detected, around six weeks of pregnancy; and the other to ban abortion for women seeking to terminate a pregnancy because of an unborn child's sex, race, color, national origin or the diagnosis or potential diagnosis of Down syndrome or any other disability.

Meanwhile, a federal appeals-court recently upheld a 2017 Kentucky law that requires women to have an ultrasound before having an abortion while their doctor displays the image and offers a medical description of the fetus with the heartbeat played loud enough for the woman to hear. The law allows the woman to avert her eyes from the image and to ask for the heartbeat volume to be turned off, but not to refuse the procedure.

Addict who writes a column says addicts are best helped by recovering addicts, with help of families, communities, politicians

Lee's book of columns

By Phillip Lee

As a recovering addict, I know first-hand the devastation and agony families face all across the United States. I know many think it is of our own free will that we use or used drugs. Many feel that it is a stigma on society, and that those right in the middle of the stigma themselves should be cast aside, thrown in prison for all of life or worse. Many feel that the world would be better off if addicts or recovering addicts would simply disappear from the earth, altogether.

While each American citizen is entitled to feel about this disease as they wish, the facts are here in black and white for anyone to read. The facts are in your communities, neighborhoods and towns. They are in almost every walk of life and in every facet of humanity, and no matter how bad you or I wish there weren’t even such things as addictions or drug abuse. I thought it important to point out that we have not disappeared and no, regardless of what some may choose to believe, we do not deserve to die in prisons because we are addicts, recovering or otherwise.

In my mind and soul I know this is as a disease. Those who think otherwise because they were able to quit, limit or control their using in one manner or the other have not truly fallen victim to the manifestation of the disease. I’ve spoken with hundreds if not thousands of addicts and recovering addicts over the years. Not one of them has said, “I’m sure glad things worked out like this.” Or, “I love being an addict.” Not one that I know has ever wished this dreaded disease on anyone. I’m stuck with it and I sure don’t want it, but here I am, trying to make the best of it -- and who knows, maybe persuade the one who has never tried drugs to leave it at that. And if I can help another addict stop using and change his/her life for the better then perhaps my life had greater meaning and purpose after all.

In searching for answers and understanding myself, I’ve acquired a copy of the America’s Health Rankings 2018 Annual Report, compiled by the United Health Foundation. According to the report, Kentucky’s ranking declined from 42nd in 2017 to 45th in 2018, With only Arkansas, Oklahoma, Alabama, Mississippi and Louisiana ranking lower.

Many factors determine the overall score of the report, including obesity, illnesses and death rates associated with cancer and other diseases, as well as immunizations, physicians, counselors, economic health and other determinants. But here I wanted to express what the drug epidemic is doing to the nation and Kentucky.

It’s crazy out of control. That’s why it is an epidemic. Only Ohio, New Hampshire and West Virginia came in with worse numbers in drug deaths, according to the 2018 report. According to provisional data for 2017, there were 72,000 drug overdose deaths in the U.S. in 2017, a sharp increase from 63,000 the year before. Kentucky’s drug fatality rate in 2018 was 28.6 per 100,000 people. The national average was 16.9 per 100,000.

With trends and numbers like this it seems to me that the only answers will come from working on the problem together, without finger pointing and shaming. Who truly gains from finger pointing? Politicians? Communities? Families? Or the individual? Anyone?

How can a politician who has never been addicted come up with a solution based on his own knowledge or experience? How can law enforcement, doctors or counselors or anyone else come up with a solution to a problem they truly know nothing about on a personal level? They know what they know based on experience and academic education. They know nothing of what is truly going on in an addict’s mind, especially in the split seconds just before their addiction leads them to use again. How could they?

I believe that recovering addicts can best help other addicts recover, beyond any other way possible today. That being said, I believe there are solutions that include politicians, communities and families-along with recovering addicts whose been there and lived through the hell of active addiction.

Phillip Lee, a native of Albany, Ky., recently resumed writing his column, "The Journey of an Addict," after relapsing and going into treatment.

Ky., 43 other states sue generic drug makers, alleging price fixing; Beshear sues 3 top insulin manufacturers, making similar claim

Screenshot of CBS illustration of emails among drug makers

Kentucky is among 44 states that filed a lawsuit Friday in federal court in Connecticut, accusing 20 manufacturers of generic drugs of fixing prices and suppressing competition.

Meanwhile, Attorney General Andy Beshear announced that he had also sued the three major makers of insulin for driving up prices. In both cases, he is seeking changes in conduct, recovery of excess profits and civil penalties.

Beshear, a candidate for the Democratic nomination for governor, is one of many politicians who have targeted drug companies over price increases in the last decade. "The criticism has come from across the political spectrum," the international news agency Reuters notes. "Generic drugs can save drug buyers and taxpayers tens of billions of dollars a year because they are a lower-priced alternative to brand-name drugs." Generics account for 90 percent of U.S. prescriptions, one official told CBS News.

The generics suit claims the companies "engaged in illegal conspiracies to divide up the market for drugs to avoid competing and, in some cases, conspired to either prevent prices from dropping or to raise them," Reuters reports. The suit claims Teva Pharmaceuticals USA, the American subsidiary of Israeli-based Teva Pharmaceutical Industries Ltd., orchestrated the scheme.

Teva said in a statement, “The allegations in this new complaint, and in the litigation more generally, are just that – allegations. Teva continues to review the issue internally and has not engaged in any conduct that would lead to civil or criminal liability.”

The 500-page lawsuit "is parallel to an action brought in December 2016 by the attorneys general of 45 states and the District of Columbia," Reuters notes. "That case was later expanded to include more than a dozen drugmakers."

Since 2016, generic-drug prices have declined slightly, but "I don't think that means the conspiracy has ended," Connecticut Attorney General William Tong told CBS's "60 Minutes." He added, "If they stopped colluding, you would expect prices to go down dramatically."

Tong said his investigators found "an industry-wide conspiracy" that answers the question, "Why are prescription drugs so expensive?" He said everyone in America is affected: "It affects health-insurance premiums . . . it impacts Medicare and Medicaid, and it is a chain reaction that drives up the price of American health care to unnatural heights."

The latest suit "accuses the generic drug industry, which mainly sells medicines that are off-patent and should be less expensive, of a long history of discreet agreements to ensure that companies that are supposedly competitors each get a 'fair share'," Reuters reports.

The suit seeks damages, civil penalties and actions by the court to restore competition to the generic drug market.

In the other case, in Franklin Circuit Court, Beshear sued Eli Lilly & Co., Sanofi-Aventis Pharmaceuticals and Novo Nordisk, alleging that they "have increased the price of their analog insulin products at least 10 times, while the costs to make insulin have stayed low, usually less than $7 per vial," a news release from his office said. "The wholesale price has jumped to nearly $300 and the price paid by those Kentuckians hit hardest by the deception can exceed $1,000 a month."

The suit "alleges that Kentuckians without insurance or on high-deductible health plans, Medicare Part D recipients, and those who pay co-insurance are hurt most, as they are forced to pay the full amount or a percentage of the artificially inflated list price of the drug," the release says. "The companies who control the drug market, pharmacy benefit managers, pay a lower, negotiated price. As a result, Kentuckians pay too much for their insulin, while the PBMs profit by paying less. Through this deceptive strategy, drug makers curry favor with PBMs and are able to not only retain profits, but also increase their number of sales."

Beshear noted that Kentucky has the seventh highest rate of diabetes in the nation.

In May 21 Democratic primary for governor, Beshear talks most about health care, but Edelen questions his past contributors

L-R: Former state auditor Adam Edelen, state House Minority Leader Rocky Adkins and Attorney General Andy Beshear answered questions from Matt Jones at a debate in Lexington April 24. (Associated Press photo by Timothy D. Easley)

By Al Cross
Kentucky Health News

If health issues matter when it comes to your vote for governor in the May 21 primary election, the candidates have given you a few things to think about.

In the Democratic primary, Attorney General Andy Beshear has cast himself as the main defender of the 2010 Patient Protection and Affordable Care Act, which his father, then-Gov. Steve Beshear, used to expand Medicaid to many more of the state's working poor.

State House Minority Leader Rocky Adkins and former state auditor Adam Edelen also support the Medicaid expansion, and oppose Gov. Matt Bevin's plan, twice blocked by a federal judge, to require "able bodied" Medicaid beneficiaries to work, volunteer or perform other "community engagement."

Bevin's leading Republican primary foe, state Rep. Robert Goforth of Laurel County, favors the expansion and Bevin's plan to change it, said his campaign manager, T. J. Litafik.

All three Democrats have endorsed the legalization of medical marijuana, but Edelen also calls for decriminalization of possession of a half-ounce or less, to reduce jail costs and fund drug treatment, and he has criticized Beshear's plan to tax medical marijuana as part of a plan to shore up state revenues and pensions.

Edelen is attacking Beshear for the campaign help he got in 2015 from Altria Group, the nation's largest tobacco-products manufacturer, and Purdue Pharma, the maker of Oxycontin, the painkiller that primarily fueled the nation's opioid epidemic. At the time, Beshear was in a law firm that represented Purdue Pharma, but has said he took no part in its cases.

On Oct. 19, 2015, Purdue Pharma gave $100,000 to the Democratic Attorneys General Association, which was supporting Beshear in the nation's only fully competitive race for attorney general. On the same day, the DAGA got its second $25,000 contribution of the year from Altria, the tobacco firm that makes Marlboro cigarettes and now owns 35 percent of Juul Labs, maker of the most popular form of electronic cigarette.

Also on Oct. 19, DAGA sent $250,000 to groups in Kentucky running ads attacking Beshear's opponent, Republican state Sen. Whitney Westerfield of Hopkinsville. All told, it spent $1 million to help Beshear, who beat Westerfield by only 2,201 votes, 0.2 percent of the total. The Republican Attorneys General Association spent more than twice as much to help Westerfield.

Just before Beshear took office, Attorney General Jack Conway settled for $24 million a lawsuit that his predecessor, Greg Stumbo, had filed against Purdue Pharma in Pike County for its role in the opioid epidemic. After Beshear became attorney general, Purdue got Circuit Judge Steven Combs to seal the case file, including the only known deposition from a member of the family that owns the company. Stat, the medical-and-science publication of The Boston Globe, asked the judge to unseal the file, and Beshear's office took no position on the issue.

The judge unsealed the file, and the Court of Appeals upheld him, but Purdue has appealed to the state Supreme Court. The deposition of Richard Sackler, then head of the company, includes emails in which he endorses a lieutenant's recommendation that Purdue not "correct the false impression among doctors that OxyContin was weaker than morphine, because the myth was boosting prescriptions — and sales," Stat reported in February, after the deposition was leaked to ProPublica.

Beshear has responded to Edelen's attack with an ad noting that he has filed nine lawsuits against drug makers over the epidemic, and “won’t take their money.”

Beshear has emphasized health care more than any other candidate, calling for "lowering the cost of prescription drugs and holding pharmaceutical companies accountable" and putting a cap on Medicaid drug spending. He has published a plan on the issue that largely supports the provisions of the federal Patient Protection and Affordable Care Act.

Beshear said in his first ad that he is "helping lead a national effort to protect coverage for pre-existing conditions," the most popular feature of the act. He is among 16 Democratic attorneys general fighting a ruling by a federal judge in Texas that declared the act unconstitutional. On Twitter immediately after the ruling, he said, “I will lead the fight to overturn” it, but at a news conference said he would be "as vocal if not more vocal" than the others.

Ads from Beshear and Edelen both criticize Bevin on health care. Edelen claims the governor "sold out to the insurance companies, let them jack up premiums and kick thousands off their health care."

Asked how Bevin sold out, Edelen spokesman Matt Erwin said in an email, "Matt Bevin supports the elimination of the ACA in its entirety. Nobody would benefit more . .. than the big insurance companies who could return to denying coverage for those with preexisting conditions and offering plans that don't even provide coverage for basic health care services." He said Bevin's Medicaid plan would "cause tens of thousands of Kentuckians, if not more, to lose coverage."

Bevin's plan estimates that after five years, Kentucky's Medicaid rolls would have 95,000 fewer beneficiaries than without the plan, in large measure for failing to comply with its community-engagement and reporting rules. Tens of thousands of Kentuckians go on and off Medicaid each month as their eligibility changes. About 1.4 million Kentuckians are on the program, more than 400,000 through the expansion.

Adkins has stayed out of the Beshear-Edelen fray, hoping to be the alternative, and emphasizes education and economic development. His website notes that he and his running mate for lieutenant governor, Stephanie Horne, "are both cancer survivors and know the pain and cost of unexpected illness, and that's why they want to make sure every Kentuckian has access to health care."

Ky. proposes ban on tattooing over scars, but won't say why; public comment on proposal taken through May; hearing May 28

5/24/19: This story has been updated with information from a Cabinet for Health and Family Services news release. 

 Kentucky health officials are proposing to ban tattooing over scars, without giving a reason for doing so, drawing criticism from doctors and tattoo artists, Lisa Gillespie reports for Louisville's WFPL.

WFPL photo

The proposal doesn't offer a reason for the change and simply reads, "Tattooing of scarred skin is prohibited."

A statement from Doug Hogan, chief spokesman for the Cabinet for Health and Family Services, also didn't give a reason for the change.

“Regulations in this area have not been updated for about 15 years. Public comments are being accepted through the end of May,” Hogan wrote. He said the Department for Public Health “will review and analyze all comments and then determine what changes, if any, need to be made to the regulations.”

UPDATE: On May 24, the Cabinet for Health and Family Services issued a news release that said the cabinet made the change to the regulation to address the potential health issues of tattooing over unhealthy skin.  However, Health Commissioner Dr. Jeffery Howard said, "The specific language in the proposed regulation had some unintended consequences and will be addressed. . . . we believe the final regulation will be improved by the comments we have received." The release notes that the language regarding tattooing over scarred skin will be addressed once the public comment period has ended on May 31st.

David Levine, a researcher and doctor at the Morehouse School of Medicine in Atlanta, told Gillespie that he doesn’t know of any medical research that would warrant such a ban and that he thinks the proposal is written too broadly.

“It probably should have been more specific to the reason that the skin was scarred in the first place,” Levine said. “There are people that are using cosmetic tattooing to actually reduce the appearance of scars.”

Levine did caution that tattoo artists should avoid one type of scarring: a keloid, a raised scar that spreads across the skin, because the process of tattooing would likely lead to more of them. Gillespie reports that this type of scar is most common in African Americans, Asian Americans and Latinos.

Mike Martin, president of the Alliance of Professional Tattooists, told Gillespie that the industry already has rules in place about tattooing over scars, and there is typically no problem as long as the scar isn't fresh. He added that he had never heard of such a ban.

Buddy Wheeler, the owner of Tattoo Charlie’s in Louisville and Lexington, listed several reasons why people cover up scars with tattoos, including cancer survivors who want to cover their mastectomy scars.

Public comments on the proposal are being accepted through the end of May. Comments can be emailed to: CHFSregs@ky.gov. A public hearing on the measure is scheduled for May 28 in Frankfort.