Evolent Health to buy 70% of Passport Health Plan; will continue to serve the company's more than 300,000 Medicaid beneficiaries

Evolent Health, a for-profit national health management company, has agreed to purchase Passport Health Plan, the struggling, nonprofit Medicaid insurer based in Louisville.

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Evolent, which has provided services and staff to Passport since 2016, will purchase a 70% share of Passport for $70 million, and invest additional funds to shore up the company's finances.

Passport has struggled since the state cut its Medicaid rates for the Louisville region last year, where it does most of its business, notes Deborah Yetter of the Louisville Courier Journal.

Scott Bowers, Evolent's national Medicaid president, has been named the new CEO of Passport, replacing Mark Carter on June 7, Yetter reports. Carter will remain on for a period as an adviser.

The company will continue to serve the more than 300,000 Kentuckians who get their Medicaid health coverage through Passport and will continue to operate under the same name, it said.

The remaining 30 percent of Passport will remain with its founding members, including the University of Louisville, the U of L Medical Center, University of Louisville Physicians, the Jewish Heritage Fund for Excellence and Norton Healthcare. U of L will get nearly $45 million from Passport's sale to Evolent, Morgan Watkins reports in a separate Courier Journal article.

The university owns 64% of Passport, and 70% of that will be sold for about $44.7 million, U of L President Neeli Bendapudi told reporters. That will leave it with a 19.2% stake in the company.

Bendapudi said $16 million from the sale would be used to retire U of L Physicians' bank debt; $3.5 million to stabilize U of L Physicians' cash position; and $16 million to reduce the School of Medicine's deficits. She declined to provide details on the nature of the deficits, and said the sale wouldn't be enough to resolve financial issues at the school and the physicians' practice.

The deal is subject to approval of state and federal regulatory authorities including the federal Securities and Exchange Commission, a process that is expected to take 60 to 90 days.

Officials with Passport and Evolent told Yetter that they are committed to resuming work on the company's new headquarters in West Louisville, which was suspended in February. Carter and Bowers told Yetter that they are still in discussions about how to revive the stalled project.

Passport is one of five companies that manage most of the state's $11 billion-a-year Medicaid program that serves around 1.3 million people. Passport is the only nonprofit; the others are subsidiaries of for-profit insurance companies.

Passport fell into trouble last year when the Cabinet for Health and Family Services changed its geographic allocation of Medicaid money, cutting the Louisville region that Passport serves by 4.1% while the rest of the state was raised 2.2%. State officials have held firm that the new rates were developed with the aid of an independent actuary and were not aimed at any individual company.

The state recently enacted revised rates that effectively restored Passport to its original, higher rate, Yetter reports, but Carter told her that that wasn't enough to make up for the roughly $100 million it lost since July 1. He said the additional investment by Evolent should make Passport solvent.

This isn't the first time Passport, which was founded in 1997 as a pilot project to control Medicaid costs in the Louisville region at the request of state officials, has found itself in the news.

In 2010, a state auditor's report found "wasteful spending of Medicaid funds" at Passport. Along with a strong reprimand from then-Gov. Steve Beshear, the report resulted in sweeping reforms, including a restructure of Passport's board, hiring new executive leadership, cutting expenses and firing its outside lobbyists, Tom Loftus reported in a 2015 Courier Journal article.

And while Beshear asked Passport to stop spending money on anything not directly related to patient care, he later asked for, and Passport provided in May 2015, a $25,000 contribution to the Democratic Governors Association in May 2015, which had already given "$600,000 to Democratic super PAC supporting the election of Attorney General Jack Conway as governor."

Beshear and Carter told Loftus that the $25,000 was not a political contribution, but for sponsorship of a one-day health policy conference co-hosted by the DGA in Louisville. Senate Republican Leader Damon Thayer, of Georgetown, disagreed, saying, "I'm not saying this is illegal, I'm just saying call this what it is -- a political contribution." Only three states elected governors in 2015.

At the time, Conway was running against Republican Matt Bevin, now governor, and they had starkly different opinions about Beshear expansion of Medicaid to people who earn up to 138% of the federal poverty line, under the 2010 Patient Protection and Affordable Care Act. Conway fully supported the expansion, while Bevin said he would end it if elected. In July, he changed positions, saying he would seek a waiver from federal rules that would make Kentucky Medicaid more like the program in Indiana, in which beneficiaries pay small premiums based on income.

Since being elected, Bevin has sought a waiver that includes premiums and "community engagement" requirements, including work, for "able-bodied" beneficiaries. A federal judge twice rejected the plan, which is now before the U.S. Court of Appeals for the District of Columbia.

Study finds flavors in e-cigs can damage cells that are critical for a healthy heart; cinnamon and menthol flavors were the most toxic

Healthline.com photo

Flavors used in electronic cigarettes damage the cells that line the inside walls of blood vessels, which ultimately increases the risk of heart disease, a study has concluded.

The study, published in the Journal of the American College of Cardiology, exposed lab-grown endothelial cells, which normally line healthy blood vessels, to six different flavored e-liquids with varying nicotine concentrations.

The researchers found that following exposure, the cells were more likely to die early, showed increased levels of DNA damage, were less able to help form new blood vessels and were less able to participate in wound healing, Dennis Thompson reports for HealthDay News.

The study found that the cinnamon and menthol liquids were the most damaging to the cells, while the caramel and vanilla flavors were also damaging, but not as severely.

Senior researcher Dr. Joseph Wu told Thompson that if this same effect occurs in the human body, it could potentially increase the long-term risk of heart disease and stroke. Wu is director of the Stanford Cardiovascular Institute in California.

"If you're a chronic e-cigarette [user], you're probably going to be prone to more vascular disease in the future," Wu told Thompson. "It doesn't have the carcinogens associated with smoking, but don't use e-cigarettes with the assumption that if I switch to e-cigarettes it will be good for my cardiovascular health."

Wu added that endothelial cells, which line the heart and blood vessels, are critical to heart health and need to remain flexible to help manage blood pressure. Further, he said that when they are damaged they attract more cholesterol plaques and contribute to narrowing of the arteries, and stroke.

"The remarkable thing was there were very strong effects, both in terms of the specific mechanisms they looked at and that the effects were not very different between cells from e-cigarette smokers and cigarette smokers," Dr. Rose Marie Robertson,deputy chief medical officer of the American Heart Association, told Thompson.

Robertson also warned that the e-cigarette companies are using flavorings that have been approved by the U.S. Food and Drug Administration for ingestion, but not necessarily for inhalation.

Much of the concern about e-cigarettes is centered around the growing use of these products by teens, largely because they are attracted to the flavors.

"There's so many kids who are smoking e-cigarettes. And these kids are going to become adults. And these adults can become elderly patients that I as a cardiologist will take care of later on, " Wu told Michael Nedelman of CNN.

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

A national study found that vaping increased nearly 80% among high schoolers and 50% among middle schoolers from 2017 to 2018.

Wu told Thompson that the researchers suspect that different components of e-cigarette vapor might harm blood vessel cells in different ways.

Environmental Health News calls this study the latest linking e-cigarettes to heart problems and points to two other bodies of research that link e-cig use and heart disease.

In March, it reported that researchers presented a study of nearly 100,000 Americans that found e-cigarette users are more likely to suffer heart attacks and strokes compared to non-users. In January, it reported on a big national study of 400,000 Americans that found e-cigarette users have a 70% higher risk of stroke and a 60% higher risk of heart attack, compared to non-users.

Kentucky Hospital Association asks federal appeals court to uphold state plan for work rules in Medicaid

The Kentucky Hospital Association has filed a formal statement with the Court of Appeals for the District of Columbia Circuit asking it to uphold the state's proposed work and other "community engagement" requirements in Medicaid, James Romoser reports for Inside Health Policy.

Romoser called the move "a rare example of the hospital industry endorsing work requirements as a condition for maintaining health coverage."

The hospital association filed the friend-of-the-court brief May 21, asking the court to uphold Kentucky’s request for a waiver of the traditional Medicaid rules to require, among other things, most of the "able-bodied" individuals who gained coverage through the expansion of Medicaid to people who earn up to 138% of the federal poverty line to work or participate in community engagement 80 hours a month.

The new Medicaid program is called Kentucky HEALTH, for Helping to Engage and Achieve Long Term Health. It would be an experiment under a waiver of Section 1115 of the Social Security Act.

In March, District Judge James Boasberg ruled against the waiver, as well as a similar one for Arkansas, after concluding that the Centers for Medicare and Medicaid Services failed to show how work requirements would serve the objectives of the 1965 Medicaid Act.

This was the second time Boasberg had vacated the federally approved plan and sent it back to the Department of Health and Human Services for further review.

An appeal by CMS, joined by Kentucky and Arkansas, is before the D.C. Circuit. A brief has been filed, arguing that Kentucky HEALTH should be upheld because the new rules would be no different than what is already required of people who receive federally funded food assistance.

KHA's friend-of-the-court brief supports Kentucky’s effort to test whether work requirements will improve the overall health of Medicaid beneficiaries, Romoser reports.

The brief says, “In essence, Kentucky’s waiver proposal tests a limited population of Medicaid beneficiaries on the theory that linking Medicaid benefits to community engagement, similar to work-sponsored commercial insurance, may encourage beneficiaries to maintain, and use, health-care coverage even while healthy, because wellness health care tends to decrease prevalence of illness and its associated higher costs.”

The brief adds, “Will Kentucky HEALTH prove its theory true? If that could be known, there would be little need to implement it as an experimental demonstration project. But the theory is rational and has a reasonable corollary to health-care delivery.”

"The association further argues that the waiver is necessary to ensure the fiscal sustainability of Kentucky’s Medicaid program," Romoser reports. This argument was also made in the Trump and Bevin administration's brief; Boasberg firmly rejected it, noting that it is based on Gov. Matt Bevin's threat to end expansion of Medicaid to more than 400,000 Kentuckians if courts thwart his plan.

Romoser says KHA's intervention is "unusual because the hospital industry has mostly tried to stay out of the debate over Medicaid work requirements." He notes that the American Hospital Association has also not taken a stance, calling it a state issue, and that KHA did not intervene in the lower court.

Kentucky projected in its initial waiver application that its Medicaid rolls would have 95,000 fewer people in five years under Bevin's plan than without it, in large measure because of noncompliance.

Romoser says that could hurt hospitals by increasing the number of uninsured patients, but terminating the Medicaid expansion is "a scenario that would be even worse for hospitals."

KHA has long supported Kentucky HEALTH, often stating that it supports the plan as a means to protect Medicaid expansion.

Doctors worry FDA can't ensure quality of foreign generics; 80% of active ingredients in U.S. drugs come from India or China

Adobe illustration adapted by The Boston Globe

Some U.S. doctors worry that the federal government is not doing a good job of policing generic prescription drugs -- which account for 90 percent of the prescription drugs Americans use, are overwhelmingly made in India or China, and are sometimes not effective, Katherine Eban reports for The Boston Globe, in a story headlined "These pills could kill you."

"The majority of generics bought in the U.S. are made overseas," writes Eban, author of Bottle of Lies: The Inside Story of the Generic Drug Boom. "Roughly 40 percent are manufactured in India; 80 percent of the active ingredients in all of our drugs, whether brand-name or generic, are made in India and China."

Doctors at the Cleveland Clinic are among those who have confirmed problems with Indian-made generics and complained to the Food and Drug Administration, which inspects more drug manufacturing plants in other countries than it does in the U.S.

The FDA says it has a reliable review system for generics, "but American physicians — particularly those who prescribe drugs that require precise dosing — are questioning the FDA’s ability to police overseas manufacturing," Eban reports. "Do the generic drugs that the agency approves actually meet the FDA’s standards, since the agency’s own investigators have discovered staggering fraud in a number of overseas drug plants?"

Eban's story includes examples of American patients put at risk by ineffective generics. She writes that while the FDA "has struggled to police a global drug supply, U.S. patients have faced a perfect storm of consequences. The ever-climbing prices of brand-name drugs have led to our reliance on the lowest-cost manufacturers overseas. Recently, dozens of versions of the generic blood pressure medicines — valsartan and losartan — have been recalled, due to ingredients manufactured in China that contained a carcinogen that had gone undetected for years. The U.S. makes almost none of its own antibiotics anymore."

Eban opines, "Solving these problems requires a multi-pronged solution to reduce brand-name drug prices, overhaul the FDA’s foreign inspection program, and revamp a system in which regulators rely on company-submitted data to verify drug quality. But along with these efforts must come a rethink of who makes our drugs where. Shouldn’t some percentage of our essential drugs be made on U.S. soil?"

Most women with heart disease don't get enough exercise; heart disease is the No. 1 killer of women in U.S., and 5% in Ky. have it

More than half of women in the United states with heart disease aren't getting enough physical activity, and that number has increased over the past decade, a study says. In Kentucky, 4.9% of women reported they had been told by a health care provider that they had heart disease, compared to 3.2% of women nationwide, according to America's Health Rankings.

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“Physical activity is a known, cost-effective prevention strategy for women with and without cardiovascular disease, and our study shows worsening health and financial trends over time among women with cardiovascular disease who don’t get enough physical activity,” Dr. Victor Okunrintemi, the lead researcher, said in a news release. “We have more reason than ever to encourage women with cardiovascular disease to move more.”

Okunrintemi is a former Johns Hopkins Medicine research fellow who is now an internal medicine resident at East Carolina University. His study, published online in JAMA Network Open, used data from a national survey representing more than 18 million U.S. women with established heart disease. The researchers compared data from 2006-2007 against data collected in 2014-15.

The study found that in 2006, 58% of women with heart disease said they were not meeting the American Heart Association physical activity guidelines. By 2015, the number was 61%.

AHA recommends 150 minutes of moderate to vigorous physical activity per week, or about 30 minutes a day, five days a week.

The researchers also found that women between the ages of 40 and 64 were the fastest-growing age group not getting enough exercise, with 60% of them not getting enough exercise in 2014-15; that was a significant increase from the 53 percent reported in 2006-07.

They also found trends related to race and socioeconomic factors, with African American, Hispanic, and women with low-income levels and low education more likely to not get enough exercise.

It also found that the health care costs of women with heart disease who met the AHA physical activity guidelines were about 30% less, compared to those who did not meet the guidelines.

Costs for women in the study who did not exercise enough was $12,724 in 2006-07 and $14,820 in 2014-15. Women in the study who exercised the recommended amount spent $8,811 in 2006-07 and $10,504 in 2014-15.

Heart disease is the leading cause of death in American women, claiming over 400,000 lives each year, or one death every 80 seconds. It kills about the same number of women as all forms of cancer, chronic lower respiratory disease and diabetes combine, according to AHA.

Women with heart disease should talk to their provider about how to increase their physical activity, as a proven way to improve their health and to decrease their healthcare costs, the researchers say.

Ky. ranks in top 10 for adverse childhood experiences; $200,000 grant will address child trauma in Lake Cumberland area

The Louisville-based Bounce Coalition has been awarded $200,000 to work with Russell County Schools and the Lake Cumberland District Health Department to help children who deal with violence, addiction and other trauma.

The Foundation for a Healthy Kentucky grant will be used to create a rural program in Russell County and nine surrounding counties to address adverse childhood experiences, or ACES, which the federal Centers for Disease Control and Prevention defines as a term used to describe all types of abuse, neglect and other potentially traumatic experiences that occur to people under the age of 18.

The Bounce Coalition was launched in 2014 with another grant from the foundation to focus on ACES in Jefferson County Public Schools.

"The Bounce program helps build children's resilience to toxic stressors, which can lead to chronic illnesses as they grow into adulthood and keep them from thriving throughout their lives," Ben Chandler, president and CEO of the foundation, said in a news release. "Our initial work with Bounce in an urban setting showed highly promising results, and now we're going to pilot the program in a rural setting. Our goal is to create a blueprint for addressing ACEs in school settings across the commonwealth."

According to America's Health Rankings, Kentucky is in the top 10 states for ACEs, with 27% of its children having experienced two or more stressful or traumatic events on a list of 10. Kentucky Health Commissioner Jeff Howard said the national average is less than 22 %.

"This means our children are starting their lives at a disadvantage compared to kids in other states, which is why this program focusing on ACEs and childhood trauma is vital," Howard said in the release. "In order to have a better and brighter future, it is imperative that we address ACEs."

Bounce Coalition Leader Joe Bargione added that the good news is that trauma doesn't have to define these children's lives. According to the news release, research shows that children with resilience skill sets are three times more likely to be engaged in school than their peers who have no skills or whose skills are underdeveloped.

"There is a growing body of knowledge that helps individuals and organizations recognize and respond to trauma, building protective factors and shifting the perspective from 'What is wrong with this child?' to 'What happened to this child?'"he said in the release.

The Bounce program in Russell County will include professional development for teachers, staff and bus drivers, in-class observation and role-modeling, classroom discussions, peer support groups for students, and education for parents, caregivers and the entire community.

In the second year of the program, Bounce will work with the health department to deploy "train-the-trainer" programs to create a system of self-sufficiency for the community. The program will begin in August.

"This is such an exciting opportunity for Russell County Schools' staff and students," Supt. Michael Ford said in the release. "We know that when our students' emotional needs are met, they are better able to participate in the learning that is taking place in their classrooms."

Health cabinet says it will revise proposed rule that would have banned tattooing over scars, due to 'unintended consequences'

WFPL photo

After almost two weeks of mystery, speculation and complaints, the state Cabinet for Health and Family Services has explained in a news release why it wants to ban tattoos over scars, saying it wants to address "potential health issues of tattooing over unhealthy skin."

"The concerns are being heard," said the cabinet, which had declined to say why it had proposed the regulation. It offered a reason: "to address potential health issues of tattooing over unhealthy skin, including recent or healing scar tissue. Because of such potential risks, some states currently restrict tattooing of skin that has a rash, evidence of an infection, open lesions, or recent scar tissue."

The proposed regulation simply reads, "Tattooing of scarred skin is prohibited." That prompted complaints that it was written too broadly.

David Levine, a researcher and doctor at the Morehouse School of Medicine in Atlanta, told Lisa Gillespie of Louisville's WFPL that he knew of no research that would warrant such a ban. “It probably should have been more specific to the reason that the skin was scarred in the first place,” he said. “There are people that are using cosmetic tattooing to actually reduce the appearance of scars.” Those include mastectomy patients.

Health Commissioner Jeffrey Howard said in the news release, "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 said that would happen after the public comment period ends May 31.

Comments can be emailed to: CHFSregs@ky.gov. A public hearing on the regulation is scheduled for May 28 in Frankfort.

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.

Kentucky dropped one spot in latest America's Health Rankings Report for seniors, to 49th; ranked last in health outcomes

By Melissa Patrick
Kentucky Health News

A new report shows that Kentucky continues to be one of the worst states in which to grow old, which isn't great news for the one in six Kentuckians who are already over the age of 65 and the growing number of Baby Boomers who will soon fall into that category.

Kentucky ranks 49th for seniors' health in the most recent America's Health Rankings Report, down one slot from last year. Mississippi is the only state ranked worse. Kentucky has been in the bottom 10 states for senior health since 2013, the first year AHR did the report.

The report looked at 34 measures of senior health that are known to influence health, which were then broken into five categories.

Kentucky ranked in the bottom 10 states in four of the five main categories, 49th for behaviors; 47th for community and environment; 44th for clinical care; and 50th for health outcomes.

Its highest ranking was for senior health policies, 32nd. This ranking was largely driven by positive scores in two categories, one that shows Kentucky has a low percentage of seniors living in nursing homes who require a low level of care, 7.4%; and another that shows the state has a high percentage of seniors with prescription drug coverage, 87%.

Other good news is that only 5.5% of Kentucky seniors are heavy drinkers, though it was 4% three years ago. The state also has a high percentage of seniors who are managing their diabetes, 81.6%.

This year, the report also looked at how many seniors had avoided care due to cost. It found that in Kentucky, 7% of seniors said there was a time in the past year when they needed to see a doctor, but could not because of cost. Nationally, that rate was 5.2%.

It also took a national look at young seniors, between the ages of 65 and 74, and found that compared with 15 years ago, smoking rates are 16% lower, early deaths are 22% lower and those reporting they are in better health is 11% higher. However, the report also found excessive drinking in this age-group is 42% higher, obesity is 36% higher, diabetes is 36% higher and suicide rates are 16% higher.

Ongoing challenges in Kentucky

The report says its purpose is to promote data-driven discussions that can drive positive changes and improve the health of seniors -- and most of Kentucky's data shows a lot of room for improvement.

Kentucky seniors rank No. 2 in smoking, at 12.5%. The report notes that it's never too late to stop smoking, and that even in older adults it has been shown to improve health outcomes.

Kentucky also ranks in the bottom five states for several other measures.

It ranks 47th for physical inactivity, with 36% of the state's seniors reporting they were inactive. Overall, the report found that females are 1.2 times more likely than males to be inactive.

It also ranks 47th for community support expenditures, which are used for funding personal care, meals, transportation and nutrition-education programs for seniors, at $225 dollars per adult aged 60 and older in poverty, compared with the average of $571 dollars for all states.

Kentucky ranked 46th for home-delivered meals to seniors, delivering meals to only 4.9% of its seniors aged 60 and older who have difficulty living independently. The national average for this measure is 8.9%, and the top ranked state for this measure, New Hampshire, delivers meals to 37.5% of seniors in need.

Kentucky ranks as the worst state for its high number of preventable hospitalizations, at 76.6 discharges per 1,000 Medicare enrollees. The national average for this measure is 49.4.

They are also more likely to die early. The report found 2,369 deaths per 100,000 adults aged 65 to 74 in Kentucky, compared to 1,791 nationwide.

Kentucky seniors also suffer from more mental distress than seniors in other states, 10%, compared to 7.9% nationwide.

The state's seniors also rank last among states for volunteerism by seniors, with only 18.9% volunteering, and nearly last, 48th, for the number of seniors reporting high health status, 31.7%. The national average for these measures are 28% and 41.3% respectively.

Chronic disease can lead to mental-health issues, especially among seniors in isolated rural areas like Casey County

"Rural America has some of the highest rates of chronic disease in the nation – the more remote a community, the more heart disease, cancer and diabetes. And there’s a side effect from having a chronic condition many people don’t think about – depression, anxiety and even suicide," Lisa Gillespie reports for Louisville's WFPL. "This is especially true for older adults, who’ve lived their entire lives in places with little access to places to exercise, with diets high in fat and sugar and in a culture that still hasn’t given up tobacco."

Dennis and Gay Pond (WFPL photo)

Gillespie's example is Dennis Pond, 67, of Casey County. "He often feels useless, in large part because his diabetes has caused terrible pain and numbness in his feet, and that affects his ability to drive, to help out around the house, to even go out in the yard," she reports, quoting him: “The pain gets so bad that I actually feel like cutting my feet off or just taking care of myself, if you know what I mean Ending it.” But he doesn't tell his psychiatrist about such thoughts: “When they ask me those questions, I got to try to watch what I’m saying because if I don’t I’ll end up in the psychiatric unit,” he said. “I try to say no, but I have thoughts.”

"His dark thoughts are in part an outgrowth of the toll chronic conditions have taken on him. Every day, he takes blood thinners for blood clots in his lungs, pain medication for his bad back, insulin for his diabetes," Gillespie reports. "Then there’s the nerve damage from his diabetes – what he describes as thousands of needles piercing the bottoms of his feet when he walks."

Pond lives 30 miles from the nearest town and hospital, Gillespie reports, adding, "Rural residents often have a hard time accessing medical care for their chronic conditions and psychiatric care for the attendant mental health issues. That contributes to the increased risk of suicide in rural areas, which are already at higher risk because of a lagging economy and substance abuse. For example, "suicide rates in 2017 were 30 percent higher in Appalachia than in the rest of the country." Within the region, suicides were concentrated in Eastern Kentucky, West Virginia and East Tennessee, areas that struggle with high opioid-addiction rates and poverty.

Gina Piane, a professor at National University in San Diego, was one of the first researchers to link chronic disease and mental health. Giving rural youth more health and nutrition education is a key way to prevent such issues, she told Gillespie.

Psychologist John Fulton, who works in Casey County, said he tries to teach his patients coping skills and recommends that they develop a support system of friends and family if they don't already have one. "I try to say, you know, you’re sitting there focusing on the bad things, and all that’s going to do is drag you down deeper,” Fulton told Gillespie. "[I] try to get them to, you know, turn around and start thinking about, 'Well, I’ll go outside and look at dogs or I’ll watch wrestling on TV' — get their mind off the illness and how bad they feel."

"Fulton also recommends people try to develop a strong support system if they don’t already have one. That’s something Pond does have in his wife, Gay. They married in 2013 after he did work on her house," Gillespie writes. "And there might be hope for Dennis’ pain and diabetes. He’s likely going to get surgery that could increase blood flow in his feet, helping avoid an amputation."

Kentucky schools lack immunization certificates for thousands of children, worry about immuno-compromised students and staff

American Academy of Family Physicians photo

A Louisville Courier Journal analysis found that as of March, the Jefferson County Public Schools had no record of whether 4,300 students had received their shots for measles, mumps and rubella, despite a law that requires students to hand in those documents within two weeks of enrollment.

That's a story that can be told in school districts across the state.

According to the state Department of Education, in the 2017-18 school year, of the 99,113 first and sixth graders who were supposed to have immunization certificates, 7,738 of them had expired certificates, 5,993 were missing, 241 had medical exemptions and 695 had religious exemptions.

The KDE data is broken down by school and grade to show how many students have a current immunization certificate, including whether it is a provisional, standard, medical or religious certificate. The data are not broken down by type of vaccination, and current-year data aren't posted.

Jefferson County school officials told the Courier Journal that many students may have simply not turned in their immunization documents, but they worry about those who haven't been vaccinated.

"We're putting immuno-compromised children, children too young to get immunized — and pregnant teachers and pregnant moms at risk," Troi Cunningham, an immunization nurse with the state, told reporter Allison Ross about the low immunization rates in some areas.

Public health officials say about 95% of students need to be fully immunized in order to protect vulnerable kids and others who are immuno-suppressed from measles, which is highly contagious.

Jefferson County data shows that it's not just the measles, Ross reports; some schools are also missing immunization records for other diseases, like chickenpox and hepatitis A.

It's a challenge to know what to do when students don't turn in their immunization documentation, Dr. Ruth Carrico, an infectious-disease expert at the University of Louisville, told Ross.

"What do we do when a child is not vaccinated? Where do they go?"she asked. "If they get sent home, they miss out on education. If we don't send them home, they may not realize we really mean it that you need that vaccination."

Earlier this year, the Northern Kentucky Health Department barred students who had not been vaccinated against the chickenpox from attending school and all extracurricular activities at a private Catholic school because of an outbreak. One of the students sued the health department over the ban, but the courts ruled in the health department's favor.

Eva Stone, district health coordinator for JCPS, told Ross there are several obstacles to getting children immunized, including a lack of access to medical care; that very few health-care providers will give vaccines to children on Medicaid, which forces parents to take their children somewhere else, like the local health department; and that parents have told her that doctor's offices charge for copies of updated immunization records.

"This is a community issue," Stone said. "How do we make sure children have access to health care?"

Cunningham, the nurse with the health cabinet, told Ross that the state is trying to encourage pediatricians and other health-care providers to use the state's immunization registry to keep track of patients' vaccinations.

Bevin and Trump agencies argue work requirements in other public-assistance programs pave the way for likewise in Medicaid

The administrations of President Trump and Gov. Matt Bevin argue that Kentucky's proposed Medicaid program, which includes work and other "community engagement" requirements, should be upheld because the new rules would be no different than what is already required of people who receive federally funded food assistance, Darla Carter reports for Insider Louisville.

In briefs filed last week with the U.S. Court of Appeals for the District of Columbia, they maintain that Health and Human Services Secretary Alex Azar used proper judgment to approve the state’s new Medicaid plan, which called for a waiver of the traditional Medicaid rules to require some "able-bodied," non-elderly Medicaid recipients to work or participate in a list of approved community engagement activities 20 hours a week to get their health benefits.

The official name for the state's new Medicaid plan under the Section 1115 waiver is Kentucky HEALTH, for "Helping to Engage and Achieve Long Term Health." The administrations liken the work rules to those already in use by food-aid programs such as the Supplemental Nutrition Assistance Program, formerly food stamps, and Temporary Assistance for Needy Families (TANF), generally known as "welfare."

“There is no reason why a Section 1115 waiver cannot test a community-engagement program in Medicaid, given that SNAP and TANF already have work-oriented programs,” the state argues in its brief. “Surely Section 1115 allows the secretary to test whether long-standing work-oriented programs from other public-assistance programs will work in Medicaid."

Carter reports in detail about the brief, which is part of an appeal from the March decision by District Judge James Boasberg that stopped similar plans proposed by Kentucky and Arkansas. This was the second time that Boasberg had vacated the federally approved plan and sent it back to the Department of Health and Human Services for further review. He said both times that HHS had not sufficiently considered the state's projection that its Medicaid rolls would have 95,000 fewer people in five years with the rules than without them, in large measure for failing to follow the rules.

The state takes issue with Boasberg's criticism that Azar failed to estimate the number of Medicaid recipients who would shift to other coverage because of Kentucky HEALTH, saying Azar is not required to know results in advance because that would defeat the purpose of the demonstration.

The new filing argues that Boasberg "was influenced by portrayals of the food-aid work requirements being counterproductive to low-income people, making him skeptical that a demonstration project like Kentucky HEALTH could lead to employment," but Congress disagrees, Carter reports.

The Kentucky Center for Economic Policy and Kentucky Voices for Health have reported that since last year, about 21,400 people have lost their SNAP benefits because of a work requirement in Kentucky.

Samuel Brooke, a deputy legal director at the Southern Poverty Law Center, which represented the 16 Kentucky Medicaid recipients who filed suit against Bevin's plan, said May 22: “When the waiver briefly went into effect in Arkansas, everyone saw the devastating effect it could have – thousands lost coverage in a matter of months. We are confident the appeals courts will similarly agree with the district court that the Medicaid program is designed to provide access to health care, and efforts to undercut that are contrary to Congress’s intent.”

In addition to arguing that Azar was within the scope of what is allowed and that his rationale was "careful and well-reasoned," the state says he was right in concluding that Kentucky HEALTH is likely to help sustain the state’s Medicaid program. Bevin issued an executive order last year that ends the expansion of Medicaid to people who earn up to 138% of the federal poverty line six months after any final court decision that blocks his plan.

Ky. has new tool to track the ongoing changes to its Medicaid program, including county-by-county enrollment numbers

Kentucky has a new website that shows an up-to-date timeline of all the changes in the state's Medicaid program since 2014; provides links to Medicaid resources such as contracts, court documents, state notices and research; and provides a place for people to share stories about how changes to the program have affected them or their loved ones. It also provides Kentucky-specific Medicaid data, including county-by-county enrollment.

Screenshot showing example of looking up county-by-county data on the Kentucky Medicaid Tracker

The Kentucky Medicaid Tracker is a combined project of the Kentucky Center for Economic Policy, the Kentucky Equal Justice Center and Kentucky Voices for Health.

Each of these nonprofit organizations are part of InsureKY, which describes itself as a statewide coalition of nonprofits formed to promote more affordable insurance, better care and stronger consumer protections for all Kentuckians. They support the 2014 expansion of Medicaid.

Kentucky Medicaid has seen many changes since then-Gov. Steve Beshear announced in 2013 that the state would  expand Medicaid to Kentuckians with household income up to 138% of the federal poverty line, under the 2010 Patient Protection and Affordable Care Act. Prior to the expansion, the program was limited mainly to very poor pregnant women and children, disabled people and low-income elderly in nursing homes.

Since its implementation in 2014, about half a million Kentuckians have been added to the Medicaid rolls, most of them working.

Under Republican Gov. Matt Bevin, the state asked for a waiver of federal Medicaid rules to make changes that included, among other things, work and other "community engagement" requirements for most of the "able-bodied" individuals who gained coverage through the expansion. InsureKy has strongly opposed these changes, mainly on grounds that they would create barriers to care.

The latest entry on the timeline notes that a federal judge once again blocked Bevin's proposed changes. His administration and that of President Donald Trump have appealed the ruling. The judge struck down a similar program in Arkansas at the same hearing.