Award-winning regional network organized by Norton Healthcare works to quickly treat the most deadly type of heart attack

Hospitals in the Louisville region partner with
Norton to give their patients access to the care.

Norton Healthcare has received the American Heart Association's 2019 Mission: Lifeline Regional Trailblazer Award for its regional program that provides care for a certain type of heart attack that is deadly if not treated quickly. Norton was Kentucky's only winner of the award this year, reports The Lane Report.

The program is designed to treat a type of deadly heart attack called an acute ST elevation myocardial infarction, or STEMI heart attack. ST is the distance between two junctures of an electrocardiogram.

“A STEMI heart attack begins with a sudden disruption of a mild cholesterol plaque in the wall of the coronary artery that supplies blood the heart. This leads to a buildup of a clot in an attempt to heal it. However, this clot formation results in total blockage of the artery,” Dr. Vipul R. Panchal, interventional cardiologist with Norton Heart & Vascular Institute, and medical director of interventional cardiology at Norton Brownsboro Hospital, told The Lane Report.

“It usually occurs in an artery with only mild blockage initially and can occur suddenly without warning. Unfortunately, the rapid progression to total blockage leads to loss of blood supply to the heart. The heart muscle stops working within minutes of this and dies within minutes to hours unless the artery can be opened back up.”

For a larger version of the image, click on it.

With a STEMI heart attack, quick intervention is important to restore blood flow. Diagnosis requires an electrocardiogram, and treatment requires an emergent cardiac catheterization to open the blocked artery or to administer clot-busting medication directly to the artery -- but not every hospital has emergency cardiac catheterization capability.

To combat this issue, Norton Heart & Vascular Institute established a regional STEMI network to ensure that patients from across the region have access to this lifesaving care. The network includes 12 community hospitals, emergency ground and air medical services, and three Norton Healthcare STEMI-ready hospitals, notes The Lane Report: "The goal of the network is to stabilize patients wherever they seek help and transport them to one of the receiving hospitals for cardiac catheterization to restore blood flow to the coronary artery as quickly as possible."

Panchal told The Lane Report that in 2018 Norton Healthcare had a median time of 46 minutes for its care of STEMI heart attack patients; the AHA's goal is 90 minutes or less from the time a patient seeks help to an intervention to restore blood flow.

“We see dramatically different outcomes depending on the time it takes to restore blood flow,” Panchal said.

Norton Heart & Vascular Institute STEMI Network members in Kentucky are: Breckinridge Health, Hardinsburg; Carroll County Memorial Hospital, Carrollton; Flaget Memorial Hospital, Bardstown; Jane Todd Crawford Hospital, Greensburg; Louisville VA Medical Center; Spring View Hospital, Lebanon; Twin Lakes Regional Medical Center, Leitchfield; and Norton Women’s & Children’s Hospital, Louisville. Four of the hospitals are in Indiana: Harrison County Hospital, Corydon; King’s Daughters Health, Madison; Clark Memorial Health, Jeffersonville; and Scott Memorial Health, Scottsburg.

The network receiving hospitals are Norton Audubon Hospital, Norton Brownsboro Hospital, and Norton Hospital. All three receiving hospitals have been recognized by the American Heart Association with Mission: Lifeline STEMI Receiving Center Gold awards.

Sunday, Dec. 15, is the deadline to sign up for federally subsidized health insurance, better known as Obamacare

By Melissa Patrick
Kentucky Health News

Time is running out to sign up for federally subsidized health insurance for 2020. The deadline for enrollment on Healthcare.gov is Sunday, Dec. 15, and fewer Kentuckians have enrolled than at this time last year.

Five weeks into to the six-week enrollment period, Kentucky enrollment on the federal exchange was

26,982. That was 3,190 fewer than the 30,172 who had enrolled by that time last year. Nationally, 321,165 fewer people had signed up.

The numbers for both years only reflect people who had signed up for a new plan or who had actively chosen a plan. Those who already have plans on Healthcare.gov and don't choose a new one will be automatically re-enrolled, and those numbers haven't yet been included in the enrollment reports.

Even if you have a plan on Healthcare.gov, experts say it's a good idea to look at all of your options each year to make sure you have the plan that best suits your needs or offers the best cost.

Josh Peck, the founder of Get America Covered, told Inside Health Policy that while it's concerning that the numbers are down, new enrollees are up nationally compared to last year, which "could bode well for final sign-up totals." Further, he noted that there is usually a surge of enrollment during the last weeks of sign-ups.

Don't assume you can't afford coverage, because most people using the marketplace qualify for financial help to lower their costs. In 2019, 79 percent of Kentuckians enrolled through the federal exchange qualified for tax credits and subsidies that reduced their premiums.

Update 12/10/19: A Kaiser Family Foundation report published Dec. 10 found that 31% of uninsured Kentuckians who could be shopping on the marketplace were eligible for premium subsidies large enough to cover the entire cost of a bronze plan, which is the minimum level of coverage available on Healthcare.gov.

"Rather than continuing to go without insurance, the 4.7 million uninsured people eligible for no-premium bronze plans would benefit from the financial protection health insurance offers. While bronze plans have high deductibles, they all cover preventive care with no out-of-pocket costs, and a number of bronze plans cover additional services, such as a few physician visits, before the deductible. If a low-income enrollee in a bronze plan needs a hospitalization, they will likely have difficulty affording the deductible, but the deductible will also likely be much less than the cost of a hospitalization without insurance," says the report. 

A person should qualify for a federal subsidy, or a tax credit, with an income between 100% and  400% of the federal poverty level. The federal government has an online calculator that indicates whether you fall into this bracket.

Consumers should also be wary of plans that appear to meet the Patient Protection and Affordable Care Act standards, but actually don't. That's because President Trump's administration, which has tried to weaken "Obamacare" after failing to repeal it, has loosened restrictions on plans that aren't compliant with the ACA, called "short-term plans," which are less expensive but offer less coverage.

The best way to make sure your plan is ACA-compliant is to shop on Healthcare.gov; if you are working through an insurance broker, say you want an ACA-compliant plan.

Where can I find help? 

The state-based call center is available at 855-459-6328 to help assist Kentuckians with where to go for coverage, answer questions and pre-screen for eligibility. The Healthcare.gov customer service center (800-318-2596) is also available 24 hours a day, seven days a week. Click here to find an application assister or an insurance agent near you.

Carol Adkins, coordinator of community engagement and outreach for the Kentucky Primary Association, encouraged Kentuckians who are signing up for health insurance on Healthcare.gov to talk to an application assister each year before they sign up because plans often change and premiums and options fluctuate.

"Always make plans to meet with a free, certified application assister to help you apply or re-certify," she said in an e-mail. "They are trained to help with the initial application, answer questions, explain options, assist with enrollments and more."

She stressed that  assisters are not agents and do not benefit in any way from your enrollment, but are simply there to help you with your application at no cost to you. She also noted that KPCA has assisters that specifically work on connecting children with coverage all over the state.

If you miss the deadline, the only way you'll be eligible to enroll in or change your health plan for 2020 is if you qualify for a special enrollment period. To qualify for special enrollment, you must have a qualifying life event such as a change in family status (for example, marriage, divorce, birth, or adoption of a child), change in residence, or loss of other health coverage (such as loss of employer-based coverage, or loss of eligibility for Medicare or Medicaid).

Ky. is 43rd in annual health rankings, with high rates of cancer deaths, smoking, physical inactivity, mental distress and more

Even though Kentucky moved up two spots in this year's America's Health Rankings, at 43rd, it remains one of the 10 unhealthiest states. That's where the Bluegrass State has been since the rankings were first released in 1990, with the exception of 2008, when it ranked 39th.

The 30th annual report examines 35 measures of health that include factors that influence health, broken into four categories: behaviors, community and environment, policy and clinical care, and health outcomes. Kentucky ranked 42nd for the factors, which are also called determinants, and 44th for outcomes.

To enlarge any chart from the report, click on it.

Kentucky got its best score for policy, 20th among the states. This higher ranking was largely driven by the state's low share of uninsured adults, 5.5 percent, a rate driven down by the commonwealth's embrace of the Patient Protection and Affordable Care Act and its expansion of Medicaid. Another major factor was the percentage of young children who have been immunized, 71%.

It ranked 29th in the community and environment category, which includes one of the state's strengths, a low prevalence of violent crime.

It should come as no surprise that the behavior category, which includes drug deaths, obesity, physical inactivity and smoking, is the one where Kentucky ranks the lowest, since these are some of the state's greatest ongoing health challenges. Kentucky ranked 49th in health behaviors.

Obesity in Kentucky rose this year; it declined nationwide.

The state ranks fifth for drug deaths, at 32.2 per 100,000 people; fifth in obesity, with an adult obesity rate of 36.6%; last for physical inactivity, with 32.4% of its adults inactive in the 30 days before they were surveyed; and second in smoking, with 23.4% of its adults identified as smokers.

That said, two of the state's strengths also fall in this category: a low prevalence of excessive drinking, 15.9%; and a high rate of high school students graduating, 89.7%.

Kentucky ranked 43rd for clinical care. Standing out in this category is the state's rank for preventable hospitalizations, at 76.6 per 1,000 Medicare enrollees, the worst in the nation. The national rate is 49.4. 

Kentucky ranked 44th for its health outcomes. It placed in the national top 10 for six bad outcomes: first in cancer deaths; second for frequent mental distress; fourth for premature deaths; fifth for frequent physical distress; seventh in diabetes, with a rate that has jumped from 12.5% to 13.7% in the last four years; and ninth for cardiovascular deaths.

The online report also comes with an interactive "Adjust My Rank" tool that lets you select four to eight measures and see what kinds of changes would need to happen to improve Kentucky's health ranking. For example, it shows that if Kentucky was able to raise its high school graduation rate to 93.8%, decrease its obesity rate to 32.8%, decrease its smoking rate to 20.2% and decrease its physical inactivity rate to 28.6%, it could dig itself out of a bottom 10 ranking and rank 39th again.

Flu spreads as holidays begin; get vaccinated, don't shake hands, and really wash them; it shouldn't be just 'getting your germs wet'

By Melissa Patrick
Kentucky Health News

Kentucky has seen 785 laboratory-confirmed cases of influenza since the flu season started in late September, and health officials say there are many more. So far the hot spot has been around Hazard.

A recent uptick in cases has prompted the state health department to upgrade the state's flu activity level to "regional," a classification that is applied when increases in flu cases have been confirmed in at least two, but fewer than half, of the state's 17 regions.

According to the weekly influenza surveillance report, during the week of Nov. 17-23, 275 new cases were reported in Kentucky, with increases in four of the state's 17 regions. No flu-related deaths have been reported this season.

Last season, the state had 17,665 confirmed cases and 196 flu-related deaths, including two children.

A county-by-county map shows that Perry and Jefferson counties have reported the most cases. Perry County, which has about 28,000 people, has reported 155 cases this season, with 60 of them during the week of Nov. 17-23. Jefferson County, which has more than 750,000 people, has reported 149 flu cases, with 91 surfacing that week.

Counties bordering Perry were also high on the list: Knott with 65 cases, Leslie with 69, and Letcher with 35. Nearby Pike County had 49. Bullitt County also had 35 cases. That said, every region of the state has seen some flu activity this season.

Scott Lockard

Knott, Leslie, Letcher and Perry counties are all in the Kentucky River District Health Department in Eastern Kentucky. Its director,  Scott Lockard, said the actual flu numbers are likely higher since they only include lab-confirmed cases, and providers often quit testing for flu when they are in the full swing of the season. "We've had a lot more sick people than that," he said.

Lockard said the best way to prevent the flu is to get vaccinated each year. He said his health department is constantly working to encourage people to get vaccinated and to dispel much of the misinformation that persists about immunization.

"It's an uphill battle with education about that," he said. "It just concerns me that there's so much misinformation about vaccines in general and flu vaccines."

For example, he said, many people believe things that are just not true: that getting a flu shot will cause them to get the flu, or that it's better to get the flu than the vaccine, especially if they are in generally good health.

Lockard stressed that getting a flu shot is not just about an individual's self-protection, but is also about protecting the community by promoting "herd immunity," which occurs when enough people have been immunized against a disease to protect others who are not immunized. Some can't get vaccinated because their immune systems are too weak, or because they are too young.

"It's not always about you, it's about your elderly grandmother that you go see. It's about the baby you are around," Lockard said, adding later, "I think people underestimate the flu. They don't realize how deadly it can actually be to our very old and our very young."

So far this season, about 250 of Kentucky's 785 lab-confirmed cases have been in children under 10, and about 100 have been among those from 10 to 20, highlighting the importance of getting children vaccinated -- especially because they are more vulnerable to serious complications of the flu, including death.

Lockard also advised to not underestimate the importance of following good hygiene practices to prevent the flu, like covering your cough and making sure you are washing your hands with soap and water for at least 20 seconds.

"There's a big difference in washing your hands and getting your germs wet," he said.

He also stressed the importance of avoiding close contact with those who are sick, staying home when sick, and keeping frequently touched surfaces -- like door knobs and handrails -- clean and disinfected. He also discouraged shaking hands with others during the flu season, calling it "the worst thing you can do." That can be hard during the holiday season, but flu is very contagious.

Flu symptoms include fever, headache, cough, sore throat, runny nose, sneezing and body aches.

Persons who develop symptoms should contact their medical provider immediately to determine if they are a good candidate for treatment with an antiviral drug, which could shorten the course of the illness or reduce its severity.

The federal Centers for Disease Control and Prevention recommends that everyone over six months of age get a flu shot, and it especially encourages people who may be at higher risk for complications or negative consequences to get one, including children 6 months to 5 years old and their caregivers; women who are or might be pregnant during flu season; people 50 and older and their caregivers; obese people; those with chronic health problems; residents of long-term care facilities, and health-care workers.

Vaccinations can be given any time during the flu season, but take about two weeks following the administration of the vaccine for the recipient to develop protection from the flu.

If you're looking for a place to get your flu shot, the CDC offers an interactive "flu vaccine finder" that allows you to type in your ZIP code to find nearby locations that offer shots. Local health departments offer the vaccine. Medicaid and Medicare and most private insurance providers cover flu vaccination at no cost to the patient as a preventive service.

Researchers find mental health of parents matters when it comes to child obesity; study also examined role of income and rurality

As more of the nation's children become overweight or obese, especially in rural areas, researchers are beginning to look beyond some of the known causes, like inactivity and a poor diet, to other contributors, like the mental health of their parents.

One such study, using data from 14,733 children between the ages of 10 and 17 in the 2016 National Survey of Children's Health, found that both the mother and father's mental health were associated with their child's weight, but only the mother's association remained significant after the data were adjusted for children's food security, physical activity and screen time.

More than one in five Kentucky children between 10 and 17 are obese, ranking the state third in the nation, according to a new report from the Robert Wood Johnson Foundation.

The study, published in The Journal of Rural Health, also found that children were more likely to be overweight or obese in homes with household incomes that were double the federal poverty level or less, and less likely in other households. This comparison found little rural and urban differences.

Among rural families, 44.1% of children in low-income families were either overweight or obese, compared to 32.9% of those in high-income families. Among urban families, 40.4% of children in low-income families were either overweight or obese, compared to 28.3% in high-income families.

The study also found that among higher-income families, positive mental health of either parent was associated with lower odds that the child would be overweight or obese, but those odds persisted only in regard to the mother's mental health after adjusting for other possible causes such as food insecurity, physical activity and screen time.

The mental health status of the parent was determined by this question: "In general, how is your mental or emotional health?" Those who answered "excellent" or "very good" were placed in the "positive mental health" category and those who answered "good," "fair" or "poor" were not.

"Our findings highlight the need to address maternal mental health in rural settings in order to address the physical health of the child," the researchers wrote. "We show that mothers’ mental health (in rural settings) remains associated with child weight among high‐income rural families despite adjustment for known individual, child‐level risk factors for obesity."

The report also points to the "novel association" between a father's mental health and a child's weight, noting that the lack of association after the data were adjusted could reflect a more "transactional relationship" that often exists between fathers and children, compared to mothers' supportive.

"This might explain why the variables of family food security, child physical activity, and child screen time moderated the association between paternal mental health and child weight," the researchers write.

The report notes that the study only looked at data at one point in time, which leads to the potential for "reverse causality." For example, overweight and obese children may experience more stress at school, which could have an affect on their parent's mental health instead of the parent's mental health instead of vice-versa. The report acknowledges that the mental-health data is self-reported.

"Despite these limitations, we found associations between mental health and child overweight/obesity," the researchers write. "In addition, these national‐level data provide evidence that the rural–urban differences in obesity prevalence among children may be secondary to distributions of income, as we observed no difference in the rural prevalence of overweight/obesity after stratifying by income."

Pharmacies could help get more teens vaccinated for a virus that causes sex-related cancers, in which Kentucky leads the nation

Alabama Department of Public Health

There's a vaccine for a virus that causes sex-related cancer, but rural teens are less likely to get it or know about it. Rural pharmacies could help improve vaccination rates, writes Casey Daniel, a Ph.D. pharmacist who teaches in the family medicine department at the University of South Alabama.

"Human papillomavirus (HPV) is the most common sexually transmitted infection, with 80 million Americans currently infected and 14 million new cases of infection each year," Daniel notes, but only about two-thirds of 13-to-17-year-olds start the HPV vaccine series, and fewer than half have up-to-date vaccinations. Kentucky's rates are much lower; less than half get any shots and only a third get the full series. Probably due to that, the state has the highest rate of HPV-related cancers in the nation.

Rural HPV vaccination rates are 11 percent lower than urban rates, partly because rural areas have fewer health-care providers, Daniel writes in the Journal of Rural Health. He says that gap could be filled by pharmacies, which are more widespread than doctors' offices and open longer hours. "In the 2018 President's Cancer Panel report on HPV vaccination for cancer prevention, pharmacies were specifically recommended as a way to increase vaccine accessibility," he writes. "Most pharmacies are also ideally suited for immunizations because of their inherent infrastructure and storage capacity for various medications. Many pharmacies offer vaccines such as flu, pneumonia, and shingles, and therefore, they have established immunization protocols that can be easily adapted to HPV."

Convenience is important for HPV immunization "because this vaccination is a multi-dose series requiring subsequent visits," Daniel writes. "While large chain pharmacies have a broad, mass market appeal, there is a considerable case to be made for collaborating with 'community pharmacies' as alternative settings for HPV vaccination, particularly in rural and small-town settings. In these areas, independent community pharmacies are often an established part of the community. Community pharmacists frequently have personal relationships with their patients, knowing them both within and outside the bounds of the pharmacy, and have a unique, established trust. They are trusted providers within the community, acting as the first line of health care and consultation for many patients."

That's also important for HPV immunization because research has shown that rural parents are less likely to be aware of HPV and the vaccine. Community pharmacists "frequently have personal relationships with many local individuals," Daniel writes. "Therefore, they can function in both education and reinforcement regarding the importance of HPV vaccination. . . . In the exploration of alternative settings to increase HPV vaccination, community pharmacies have been significantly overlooked. Particularly in rural settings, these pharmacies have vast potential to reach under-served, disparate populations and serve crucial roles in addressing community health care needs and filling resource gaps."

Bullitt County schools to sue Juul, alleging it created e-cigarette epidemic that has cost schools money and instructional time

Bullitt Central High School Principal Joe Pat Lee watches students arrive on opening day. (BCPS photo)

The Bullitt County school board voted Nov. 25 to sue Juul Labs and other manufacturers of electronic cigarettes, as well as distributors and retailers.

"Bullitt County Public Schools, like every other school district in the country, has witnessed a dramatic increase in the use of vaping products by its students," the board's resolution said. "The targeting of school children by these companies in their marketing campaigns has resulted in an epidemic of nicotine addiction in children."

Juul Labs is the leading maker of e-cigarettes and has used research by traditional cigarette companies to make its devices the most popular and, critics say, the most addictive.

School Supt. Jesse Bacon said in a news release, “In recent years, we have seen a dramatic increase in the number of infractions that involve vaping in our middle and high schools. The amount of resources being used and the instructional time that is lost as a result of this issue is alarming, to say the least.”

Ron Johnson, the attorney hired to file the lawsuit, said it would be the first such suit by a Kentucky school district. "This year in Kentucky, there have been four lawsuits filed against Juul and more than 100 around the country," Sarah Ladd reports for the Louisville Courier Journal.

Juul Labs used research that tobacco-cigarette manufacturers wanted to use to get young people to become addicted to nicotine

In this screenshot of an April 2016 video, recently removed from YouTube, a co-founder of Juul Labs, James Monsees, presents an R.J. Reynolds research memo (YouTube image via Los Angeles Times)

In developing the world's most popular electronic cigarette, the founders of Juul Labs used the decades-old research of tobacco companies that was aimed at getting young people to smoke.

"A review by the Los Angeles Times of more than 3,000 pages of internal Juul records, obtained by the Food and Drug Administration and released to a researcher through the Freedom of Information Act, found that the concept behind the formula that makes Juul so palatable and addictive dates back more than four decades" to the laboratories of R.J. Reynolds Tobacco Co., the nation's No. 2 cigarette maker, Emily Baumgaertner reports for the Times.

"The key ingredient: nicotine salts," Baumgaertner writes. "Juul’s salts contain up to three times the amount of nicotine found in previous e-cigarettes. They use softening chemicals to allow people to take deeper drags without vomiting or burning their throats. And they were developed based on research conducted by the tobacco companies Juul claimed to be leaving behind. . . . The evidence depicts a Silicon Valley start-up that purported to 'deconstruct' Big Tobacco even as it emulated it, harvesting the industry’s technical savvy to launch a 21st century nicotine arms race."

Juul "acknowledged that the product intentionally 'mimicked' the nicotine experience of a traditional cigarette," but said that was to satisfy cravings of adult smokers, not children, Baumgaertner reports. "But a new generation of nicotine addicts has already been established, and health experts warn that millions of teenagers who currently vape could ultimately turn to other products like cigarettes for their fix."

A now-dead R.J. Reynolds researcher wrote in a confidential internal memo in 1973 that teenagers found the physical effects of smoking “quite unpleasant.” Later that year, another researcher proposed a cigarette design to get “a larger segment of the youth market” by packing “more ‘enjoyment’ or ‘kicks’ (nicotine)” while making it easier on the throat. An RJR chemist did that by using an acid to neutralize the high alkalinity of nicotine, creating a nicotine salt.

An RJR spokesperson told Baumgaertner that the research was intended to “reduce the risks” of smoking while “maintaining nicotine delivery,” and while the salts were patented, they were never used in a traditional RJR cigarette. In the late 1980s, RJR and three other cigarette makers "agreed to begin paying billions of dollars to compensate states for having knowingly propelled a smoking epidemic," Baumgaertner writes. "Within this climate, the company was unable to combine its two technical triumphs — palatable salts and early vaping equipment."

But RJR's research was used by Juul's developers, Baumgaertner reports: "Juul records show the start-up collected research done by tobacco experts about nicotine — work on using salts to control harshness, written by a former top scientist at Reynolds, as well as methods to maximize nicotine delivery, and piles of literature on nicotine’s impact on adolescent brains."

Juul cofounder James Monsees said at a 2018 conference, “Certainly, the nicotine salt chemistry was one of the big breakthroughs.”

The patent for Juul's nicotine-salt formula refers to RJR's patent, saying Juul's founders “unexpectedly discovered” the “efficient transfer of nicotine to the lungs of an individual and a rapid rise of nicotine absorption in the [blood] plasma.”

David Kessler, a pediatrician who headed the Food and Drug Administration in 1990-97, during its tobacco investigation, told Baumgaertner, “Addiction is central to the business model. With their nicotine salts, Juul has found the Holy Grail.”

Before Juul was introduced, "Most vaping fluids contained 1% to 3% nicotine, the latter described as 'super high' and intended for two-packs-a-day smokers,: Baumgaertner reports. "Juul offers pods that contain 5% nicotine, according to the company’s website. . . . From 2016 to 2017, Juul’s sales skyrocketed by more than 640%. Its cartridges were so palatable that teenagers sometimes raced one another to finish inhaling them. Many said they didn’t know the pods contained nicotine. Each 5% cartridge contained the nicotine equivalent of about 20 cigarettes."

Matthew Myers, the president of the Campaign for Tobacco-Free Kids, told Baumgaertner, “Juul mimics the evil genius of the cigarette — but does it even better. They also pulled it off without any of the historical baggage, giving the deceptive illusion that it was safe.”

Doctors think nicotine salts allow the chemical to “cross the blood-brain barrier and lead to potentially more effect on the developing brain in adolescents,” Anne Schuchat, chief deputy director of the federal Centers for Disease Control and Prevention said at a congressional hearing in September. She told the Times that the salts “allow particularly high levels of nicotine to be inhaled more easily and with less irritation” than earlier e-cigarettes, "and could enable nicotine dependence among youth," Baumgaertner writes.

She concludes, "Today, Juul comprises about two-thirds of the vaping market. In 2018, the largest tobacco company in the U.S.," Altria Group, "purchased a 35% stake in Juul. After the purchase, several of the tobacco company’s employees also started working at Juul . . .In September, Altria’s former chief growth officer, K.C. Crosthwaite, became Juul’s CEO."

Kentucky state senator taken aback by 'shoutfest' in White House between electronic-cigarette interests and their foes

State Sen. Julie Raque Adams speaks in the White House Nov. 22 as President Trump and Health and Human Services Secretary Alex Azar listen. (Image from White House video, via WDRB-TV)

A Kentucky state senator witnessed what one report called a "shoutfest" in a White House meeting hosted by President Trump between lobbyists for health interests and those for electronic cigarettes.

Sen. Julie Raque Adams, a Republican from Louisville, "says she was taken aback by the lack of decorum shown by vaping industry executives," reports Joe Sonka of the Courier Journal.

"There was a lot of passion in that room," Adams told Sonka. "Frankfort is tamer than that meeting was."

Trump said in September that he would ban all e-cigarette flavors except tobacco and menthol, then backed off in the face of protests from users, retailers and manufacturers.

Adams got a surprise invitation to the Nov. 22 meeting only two days in advance. The White House described it as a roundtable discussion that would likely be private so the two sides could speak frankly, she said.

But soon after she voiced concern that "We have a whole new generation addicted to nicotine," and said many teenagers don't know e-cigarettes contain the drug, Trump "suddenly asked if it was OK to allow news media into the room, she said."

That is not mentioned in the White House's incomplete transcript of the meeting, which indicates that Adams was the first guest Trump asked to speak.

Adams recounted, "I said beyond anything, we have to look at keeping nicotine out of the hands of teens, because research shows that the sooner they're introduced to nicotine, they're more susceptible to become addicted to other substances. It messes with their brain chemistry. So the longer that we can keep nicotine out of the hands of teens, the better it would be for my state."

Not long after she spoke, "People started getting really loud and talking over each other," she told Sonka. "And I was really surprised in that setting that there wasn't a higher level of respect between people."

Sonka writes, "Adams added that Trump appeared to enjoy the 'free for all' to see what was driving the arguments of the different groups but cut in several times to 'rein them back in.'

"It was interesting to watch [Trump] because he was clearly not disturbed by the back and forth in the banter and the kind of aggressiveness," Adams told Sonka. "Everybody in the room was super-passionate about the issue. And then he would bring everybody back to a more respectful level, and then the passion would get wild again and then he tried to bring it back."

She said Ryan Nivakoff, CEO of e-cigarette manufacturer NJOY, and American Vaping Association President Greg Conley were "by far the loudest voices in the room," dispuiting arguments of Sen. Mitt Romney, R-Utah, who wants to ban flavored e-cigarettes.

"Nivakoff and Conley said such a ban would put companies and independent vaping shops across the country out of business while taking away an option that many adults have used to quit smoking cigarettes," Sonka reports. "However, Adams says those vaping-industry officials provided four areas in which they were ready to compromise, including raising the age limit for purchasing tobacco and vaping products to 21, a self-imposed marketing ban, increasing punishment for retailers selling to anyone under 21, and increasing oversight of vape shops by local health officials."

Adams "said she supports addressing the issue of marketing products to teens and thinks it is worth having a continued conversation about flavored products," Sonka reports. She plans to sponsor a bill in the legislative session that starts Jan. 7 that would raise the age to buy tobacco products to 21.

"Adams said she was glad to attend the meeting and to get her perspective in front of the president," Sonka writes, quoting her: "You know me, I'll work with conservatives, liberals, moderates. This issue, I'm just very passionate about it, because we save a lot of tax dollars by having a healthy Kentucky."

Substance abuse drives decrease in life expectancy in U.S., Ky.

Charts from report show impact of drug overdoses; ages 45-54 showed an increase almost as steep.

By Al Cross
Kentucky Health News

Americans are dying younger, and Kentucky is a big part of that.

The most basic measurement of a population's health, life expectancy at birth, has decreased in the United States for three straight years, and in Kentucky for four. The leading cause is drug overdoses, but there are many other factors.

In 2000, Kentucky had a mortality rate of 425 deaths per 100,000 people; in 2017, the rate was 512 per 100,000, an increase of 20 percent. Most of that increase, 14.7 percentage points, occurred from 2010 to 2017, according to a study published in the Journal of the American Medical Association.

Eight states had greater increases: New Hampshire, 23.3%; West Virginia, 23%; Ohio, 21.6% Maine, 20.7%; Vermont, 19.9%; New Mexico, 17.5%; South Dakota, 15.5%; and Indiana, 14.8%.

For a larger version of any image, click on it.

The study calculated the "excess deaths" caused in 2010-17 by the increase in midlife mortality, defined as deaths of people aged 25 to 64. It said there were 1,524 excess deaths in Kentucky, 1,839 in Indiana, 3,179 in Pennsylvania (where the mortality rate rose 14.4%) and 4,730 in Ohio. The study report said higher midlife mortality in 2010-17 "was associated with an estimated 33,307 excess U.S. deaths, 32.8% of which occurred in four Ohio Valley states."

The report said, "The increase in opioid-related deaths is only part of a more complicated phenomenon and does not fully explain the increase in midlife mortality rates from other causes, such as alcoholic liver disease or suicides (85.2% of which involve firearms or other non-poisoning methods.) . . . Two recent studies estimated that drug overdoses accounted for 15% or less of the gap in life expectancy between the United States and other high-income countries in 2013 and 2014, respectively."

Other possible causes include high rates of tobacco use (including effects that linger despite lower smoking rates), obesity and socioeconomic factors: "substantial job losses in manufacturing and other sectors, contraction of the middle class, wage stagnation, and reduced inter-generational mobility. Income inequality widened, surpassing levels in other countries, concurrent with the deepening U.S. health disadvantage. . . . Increases in death rates were concentrated in areas with a history of economic challenges, such as rural U.S. areas and the industrial Midwest."

Dr. Steven H. Woolf

The study was done by Dr. Steven Woolf of Virginia Commonwealth University in Richmond and Dr. Heidi Schoomaker of Eastern Virginia Medical School in Norfolk.

"We found increases in 35 causes of death," Woolf told MedicalResearch.com. "An increase in mortality spanning 35 causes of death is difficult to blame on a single cause, such as the opioid epidemic or obesity. The pervasive trend suggests a systemic cause, something distinct that is causing this to occur in the United States and not other wealthy nations. . . . Job losses in manufacturing and other sectors, stagnant incomes, and widening income inequality could contribute to poor health in multiple ways and would explain the disproportionate impact we observed in the Rust Belt and other areas hit hard by the economy. This suggests that, while it is important to treat the 'symptoms' of this trend (addressing drug abuse, the obesity epidemic, etc.), social and economic policies to improve education, create good jobs, and invest in communities may be even more important in reversing this trend. If we fail to act, the trend is likely to continue, and that will mean that our children will live shorter lives than ours."

New state Medicaid contracts drop Passport and Anthem, which say they will appeal; top Beshear aide voices concern

On its way out, the administration of Republican Gov. Matt Bevin has given five health-insurance companies new, five-year deals to manage the care of Kentuckians on Medicaid -- and dropped Anthem Inc. and the nonprofit Passport Health Plan, which now have contracts with the state.

The three returning firms are subsidiaries of Aetna, Humana and WellCare. The two newcomers are UnitedHealthcare Community Plan of Kentucky and Molina Healthcare of Kentucky. The new contracts would replace the old ones on July 1, unless Passport and Anthem win protests they say they will file.

On Dec. 10, Bevin will be replaced by Democrat Andy Beshear, who defeated him this month. Beshear's top aide, J. Michael Brown, issued a statement saying, “Awarding $8 billion in contracts with just 11 days left in this administration is concerning. As we move through the transition and ultimately the change of the administration, we will be taking a close look at this action.”

The insurance-company subsidiaries are known as "managed care organizations." MCOs manage the care of about 1.2 million Kentucky Medicaid beneficiaries, which costs $8 billion a year, with about 80 percent of the money coming from the federal government.

"The Bevin administration solicited bids for the contracts over the summer, but the announcement of the successful bidders has been delayed," reports Chris Otts of Louisville's WDRB-TV. The Cabinet for Health and Family Services, which oversees Medicaid, referred questions to the Finance and Administration Cabinet, where spokeswoman Pamela Trautner said in an email that contracts were awarded competitively.

Trautner wrote: "Proposals were submitted by prospective MCOs, which were evaluated and scored by a technical evaluation team comprised of subject matter experts against the evaluation criteria stated in the RFP. The RFP stated that between three and five awardees would be selected. The five highest scored vendors were selected. Because Passport and Anthem were not among the five most highly scored proposals, they were not awarded a contract."

Passport is a nonprofit formed in 1997 to get the state into the business of managed care, with the goal of saving taxpayers' money. The company said in a news release that it was "deeply disappointed" by the decision and that it plans to challenge the outcome. Anthem also plans to challenge the decision, Deborah Yetter reports for the Louisville Courier Journal.

Passport serves more than 300,000 Kentuckians on Medicaid, mostly in the Louisville region. Anthem serves 130,000 enrollees in Kentucky, mostly outside Louisville, Yetter reports.

Bevin and Passport have a conflict that predates his governorship. In May 2015, Passport gave $25,000 to the Democratic Governors Association, which supported Bevin's Democratic foe, Jack Conway. Passport said the money funded a one-day health-policy conference in Louisville. In 2018, the state cut some MCOs' payment rates, and Passport said it was hit hardest and almost went out of business. "Bevin had been critical of Passport, calling it 'poorly run'," Yetter notes.

In May, Evolent Health, a health-management firm, agreed to buy 70 percent of Passport, but told investors "that the company would likely liquidate Passport, selling it for parts, if Passport failed to win the next round of Medicaid business from Kentucky," Otts reports.

Evolent spokeswoman Kim Conquest told Yetter that the company supports Passport's decision to protest the loss of the contract and that Evolent "will continue to support efforts to keep the plan on solid financial footing. Per our agreement, we intend to proceed with the pending acquisition as planned and anticipate it will close by the end of this year.”

"Should the deal fall through, the University of Louisville, as a founding partner of Passport, could lose about $45 million from the sale," Yetter notes. U of L spokesman John Karman told her that the university is disappointed in the decision: "U of L is proud of its longstanding relationship with Passport and supports its decision to challenge the outcome of the evaluation and award process for this contract."

Yetter notes that most of the company's main revenue comes from managing care for Kentucky Medicaid. Anthem, by contrast, is one of the nation's largest health-benefit companies.

Passport spokesman Ben Adkins told Yetter that the company has about 600 employees in Louisville.

"This decision, if upheld, would have a profound impact on our 300,000-plus members whose access to care will be disrupted as a result," he told Yetter. "We strongly encourage state leaders to reconsider this decision and its devastating impact on our proud Kentucky company and the communities we serve."

The Cabinet for Health and Family Services said in its news release announcing the contracts thay they include a number of improvements, including a a separate contract with WellCare to cover all children in the state's foster-care system.

The contracts also include, among other things, provisions for tighter management of the prescription drug program, including abolishing "spread pricing," a system in which middlemen known as pharmacy benefit managers can profit by paying pharmacists less than they make from state Medicaid programs.

Louisville newspaper tracks huge, powerful and violent drug cartel's invasion of small towns in Kentucky and other states

Courier Journal illustration shows farm worker who oversaw flow of $30 million in drugs into Kentucky.

The tentacles of a huge, powerful and violent drug cartel reach from Mexico into unlikely places in Kentucky and other states, Beth Warren reports for the Louisville Courier Journal.

The "New Generation Jalisco Cartel," is known by its Spanish name, Cártel Jalisco Nueva Generación and its acronym. "CJNG’s increased distribution of fentanyl across the country has helped the synthetic opioid unseat heroin as the nation’s No. 1 killer," Warren writes. "The billion-dollar criminal organization has a large and disciplined army, control of extensive drug routes throughout the U.S., sophisticated money-laundering techniques and an elaborate digital terror campaign, federal drug agents say."

CJNG’s network reaches into "the mountains of Virginia, small farming towns in Iowa and Nebraska, and across the Bluegrass State" of Kentucky, Warren reports. "A cartel member even worked at Kentucky's famed Calumet Farm, home to eight Kentucky Derby and three Triple Crown winners. . . . CJNG members have followed relatives or friends who left Mexico for the U.S. to find jobs. The cartel exploits its connections with otherwise hard-working immigrants, said Dan Dodds, who leads DEA operations in Kentucky, Tennessee and West Virginia.

Ciro Macias Martinez, now serving a 31-year prison term, "led a double life, working as a horse groomer by day and overseeing the flow of $30 million worth of drugs into Kentucky by night before being imprisoned in 2018 for meth trafficking and money laundering, federal records show," Warren writes. "No sooner had authorities busted Kentucky's CJNG ring than the cartel replaced Macias, sending in another team. It hauled in more than 3 kilos of fentanyl, the synthetic opioid so potent that an amount as small as Abraham Lincoln's cheek on a penny can be fatal."

In Paducah, sheriff's investigators said the cartel warned a business owner who fell behind on a drug debt, "If we don’t get our money, we’re gonna kill you and your family." Russell Coleman, U.S. attorney for the Western District of Kentucky, said, “We’re fighting a war for our families, and (the cartels) are winning.”

CJ Editor Rick Green explained to readers that the paper made the effort because "It's a local story."