Mothers should try to go to full term in their pregnancies, but many are unaware of the risks of early delivery, UK study finds

Illustration by Michelle Kumata via KRT

Babies who are born before the full term of 40 weeks may have health problems later in life, since important brain development takes place in the very last stages of pregnancy. As such, mothers should try to avoid being induced early or having elective C-sections.

A study conducted at the University of Kentucky College of Communication and Information found women often don't realize the important development that takes place at the end of pregnancy, write UK doctoral student Sarah Vos and H. Dan O'Hair, dean of the college, for the Lexington Herald-Leader.

Evidence shows that early, elective births are expensive. One study found reducing the number of elective births before 39 weeks of gestation to less than 2 percent of all U.S. births would save $1 billion each year.

But many women are uncomfortable at the end of their pregnancy, are anxious to know their children are healthy, and may even ask for early induction of labor because employers aren't flexible about time off. Sometimes doctors and other providers induce women early for their convenience.

Encouraging women to go full term and telling them the disadvantages of early labor — problems feeding and a higher incidence of Sudden Infant Death Syndrome — can influence their decision. As Vos and O'Hair conclude, "Babies are worth the wait." (Read more)

Book on Appalachian health gets good review from doctor

A new book discusses the health disparities that affect rural and urban Appalachians and has won the praise of a Kentucky physician, who calls its impact "profound."

Appalachian Health and Well-Being was reviewed by Dr. Kevin Kavanagh, a retired physician from Somerset, for The Courier-Journal.

Each chapter stands alone so readers can choose topics according to their interests. One chapter focuses on obesity and discusses issues like "food deserts" and lifestyle choices. The authors "suggest policy changes for childhood obesity of health school lunches, elimination of junk food and drinks from school vending machines, and an increase in physical activity," Kavanagh writes.

The book also sets the facts straight on myths such as the high incidence of consanguinity and the use of home remedies and faith-based healing in rural Appalachian communities. The authors find Appalachian communities are no different than other rural regions in these regards.

The book, edited by University of Cincinnati scholars Robert L. Ludke and Phillip J. Obermiller, also discusses the methamphetamine epidemic. It notes that in Eastern Kentucky 377 meth labs were found in 2005, while in 2011, nearly 200 labs were found just in Laurel County alone. "For those who wish to understand the health and well-being in Eastern Kentucky, this is an insightful book which will give us all an appreciation of the herculean task that has been placed upon the Kentucky Cabinet for Health and Family Services," Kavanagh concludes. (Read more)

Biggest problem with health-care reform law is advocates' poor sales job to the American public, Rep. John Yarmuth tells C-J

By Tara Kaprowy
Kentucky Health News

The biggest problem with the federal health-care reform law is not the law itself, but the fact that "We've never done as good a job as we could have" in explaining what it is about, Democratic U.S. Rep. John Yarmuth of Louisville told the editorial board of The Courier-Journal Friday.

In his lengthy interview, Yarmuth said the problem started at the law's inception when President Obama outlined his parameters but  let Congress decide what the bill should be. "The challenge was explaining what the bill even was because we didn't know what it was going to be," he said.

The issue was compounded by the fact that, unlike energy legislation where its "impact is relatively uniform," with health care "everyone wants to know how it will affect you and your family ... and it's all different," Yarmuth said. "It's hard to market something individually to 300 million people."

Also contributing to the problem is the complexity of the subject itself, which Yarmuth likened to "the biggest Rubik's cube that ever existed," since "Every time you move one piece, 100 pieces move."

That has resulted in deeply-seated misconceptions about the law that are difficult to undo. The biggest, he said, is "that it is some form of government takeover." Those with that view note that the law's individual mandate in the law will force people to buy insurance or pay a fine, and the law will impose new rules on health-insurance companies and put many other controls on the system.

But Yarmuth argues the law uses "free enterprise and competition" to "provide more affordable care for individuals." Indeed, state insurance exchanges will feature different benefits packages from private companies from which people who qualify for the exchange can choose. People who qualify for the exchange — those who earn up to 400 percent of the federal poverty level — will be given subsidies in the form of tax breaks to help pay for their premiums. "The reason why the Republicans don't have an alternative is Obamacare was their alternative," Yarmuth said. "This was their plan: creating competition among insurers and letting them compete for individual business."

Another misconception is that people who don't have health insurance are "deadbeats," Yarmuth said. But he said 37 percent of Americans who are uninsured make over $50,000 a year and almost 20 percent make over $75,000 a year (those percentages are confirmed here). "No, these are solid citizens," he said. He pointed out that all families pay the cost of those who are uninsured, adding that an estimated $1,000 of every health insurance policy goes toward paying for uncompensated care.

Yarmuth said in Kentucky nearly $600 million is spent on uncompensated care each year. (A Kentucky Hospital Association report estimated it is far higher: $1.67 billion in 2010.) Regardless of the figure, Yarmuth said losses could be offset by expanding Medicaid, a claim supported by a report by the Urban Institute. Expansion would cover almost 300,000 Kentuckians and would cost the state $515 million through 2019, he said. "It will bring in $12 billion of federal money," he said. "Is that a good trade-off?"

Asked how provisions in the law would be paid for, Yarmuth acknowledged "If you're adding 30 million more people, it's going to add cost to the system." Ultimately, costs will continue to go up but "less than they otherwise would," he said. He referred to pre-law estimates by the Congressional Budget Office that the cost of employer-based insurance would double to $25,000 a year for a family of four, but the law seems to have slowed that trend. Yarmuth referred to an article published in the journal Health Affairs that indicated that between 2010 and 2011, overall national health-care expenditures increased by 3.9 percent. "That's the lowest rate of growth in the last 50 years," he said. "It is having an effect." The CBO estimated the law will reduce the deficit over the next 10 years by $130 billion, with an estimated $1.2 trillion saved in the second 10, Yarmuth noted. "We all knew we were on an unsustainable path."

But most still don't know that, and on Saturday, a day after the Yarmuth interview, the C-J editorial board criticized Democrats for not doing a better job getting their message out about the new law: "The problem is partially that the law is complex and 2,000 pages long. It's partially that the Republicans have successfully put the Democrats on the defensive, forcing them to defend the law to people who have already had the GOP message driving into their heads. But it's also that the Democrats don't trust that the American people will be willing or able to understand them when they defend the health-care law."

Lacking money, insurance and dentists, oral health takes a back seat, and many rural areas are barely on the bus

A dentist works at a Remote Area Medical Clinic in Wise, Va.
(Associated Press photo by Steve Helber)

Dr. Nikki Stone is a dentist who works in Hazard, Ky., at a community-run clinic. A native of the mountains, she knew that children in the region weren’t getting enough dental care, but she was still "staggered by the prevalence of dental disease when she began examining them in 2004," Margot Sanger-Katz reports for the National Journal. "Large numbers of the kids had never seen a dentist. Half had untreated tooth decay, and nearly 20 percent had urgent needs -- more than six cavities or an active abscess. She and her staff 'cried a lot,' she recalls. Crisscrossing four counties in her van, she painted fluoride on all the teeth and sent notes home with the children who needed immediate attention. In the early years, only 8 percent of those youngsters with urgent problems got the care they needed. The job was like fighting a forest fire on a mountain, she says. 'I felt like I was standing here on the line of the fire with a squirt gun.'"

In a world of medical priorities, dentistry takes a back seat to most, and In a world of health care, and rural America sometimes appears to not even be on the bus. The net result, writes Sanger-Katz, is that the United States faces a shortage of dentists that is particularly acute in poor, rural regions. "Huge pockets of the country have few (or no) providers. The federal government counts 4,503 mostly rural regions where more than 3,000 people share one dentist," she notes, "making it tough for many residents to find someone to fix their teeth."

There seems little hope for any change soon in rural America, even if the federal health-reform law survives. "It deems dental coverage an essential part of any health plan for children, but regulators have yet to spell out what insurers must cover to meet that definition," Sanger-Katz writes. "The law expands existing loan-repayment funds for dentists who relocate to underserved areas, but it offers no expansion of dental coverage for adults and doesn’t try to integrate dental health into the larger health care system."Dental disease is the largest unmet health need in the U.S. among both children and adults, according to the Pew Children’s Dental Campaign. The worst-off are the poor, the young, the old, and those in rural America, reports Margot Sanger-Katz reports.

Dental disease is among the most common reasons that children miss school. It’s the most common medical reason that soldiers can’t deploy. It is a leading cause of emergency-room visits in several states. For proponents of a freer health care market, who want patients to be motivated by financial incentives to shop around and avoid “unnecessary” care, the dental system offers a glimpse of how such a system might work. And research shows that poor oral health can lead to disease elsewhere in the body.

"For more than 100 years, dentistry has run on a separate -- and more laissez-fair -- track than the rest of medicine," Sanger-Katz writes. "Dentists have their own schools and treat patients in their own offices; fewer laws and regulations govern the field. Insurance plans typically demand high co-pays and limit their payouts for invasive procedures. About half of all dental expenses are paid out of pocket, compared with less than 10 percent of costs in the overall medical system. This is the free market. And, in some ways, it has worked: People do not drive up insurance rates by seeking frivolous procedures. Patients tend to shop around for care, and prices vary according to local economies. The rate of dental inflation, although higher than the rate for the economy overall, is lower than the rate in medicine, which is typically several points above the growth rate of the gross domestic product. (You don’t hear policymakers complain about the burden of 'runaway' dental costs.)"

“It’s very much a free market, with a greater spread between the haves and have-nots,” said Burton Edelstein, a professor of dentistry at Columbia University and the founder of the Children’s Dental Health Project. "Dental insurance is much less widespread than medical insurance; 130 million Americans lacked dental coverage in 2009, but only 50 million lacked medical coverage," Sanger Katz-writes. "And with most payouts capped at $1,000 to $2,000 per year, insurance can’t cover much beyond basic services. Medicare does not pay for dental care at all, so 70 percent of seniors lack any dental coverage, according to an Institute of Medicine report. Medicaid also fails to provide meaningful dental access for many of its beneficiaries: The program pays dentists so poorly for treatment that only about 20 percent of them see Medicaid patients." Meanwhile, seven of 61 dental schools closed in the last 30 years, meaning 2,000 fewer dentists every year, a 33 percent drop in supply, just as an older generation of dentists started retiring.

The result is a crisis. And, in a few lucky rural towns, the result looks like this: A mobile van outfitted with a volunteer dentist comes to a rural elementary school and offers free check-ups but no fillings. Or, better yet, a volunteer army of dentists, dental students and oral surgeons in a region volunteer for a two-day event at a vast arena where everyone is welcome to camp overnight for a place in line for care. Some of the dental expertise and hospitality is donated by Ronald McDonald House, or Remote Area Medical out of Knoxville, Tenn., or local community health centers. And while are limited in their ability to do much more than prevention, others can offer real dental care but no follow-up. The result is often a brutal kind of dentistry that involves, at best, mass extraction, some advice about what not to drink and explanations about how oral health is connected to overall health. (Read more)

Beshear tells feds he plans to create an insurance exchange

Gov. Steve Beshear. Photo by The
Courier-Journal

Gov. Steve Beshear has re-confirmed his plans to create a state health insurance exchange, this time telling the federal government of his intention.

Beshear sent a letter to Health and Human Services Secretary Kathleen Sebelius Tuesday saying he plans to issue an executive order soon to create the exchange, The Courier-Journal reports. After the U.S. Supreme Court upheld the federal health-care reform law, Beshear announced he would create the exchange.

The exchange will be a marketplace to shop for different packages of state-approved health insurance and will be available to people who earn up to 400 percent of the federal poverty level. To offset the cost of their premiums, those participating in the exchange will receive subsidies in the form of tax credits. The Medicaid program will also fall under the exchange's umbrella.

If they choose to run their own exchange rather than have the federal government do it for them, states must have it up and running by Jan. 1, 2014. Beshear said Kentucky has been "systematically preparing to meet the implementation deadlines set forth in the law." It has already received more than $65 million from the federal government to plan for the exchange's creation.

Kentucky is the 16th state to commit to creating an exchange. (Read more)

Chart shows impact of Medicaid expansion or rejection

A one-stop graphic that spells out what's in store for states that don't elect to expand Medicaid is the subject of a report by The Washington Post's Sarah Kliff.

The charts show governors who elect not to expand the insurance program for the poor and disabled will leave their poorest citizens without coverage.

One segment of the chart uses Arkansas as an example of what would happen if expansion is rejected. Because Medicaid eligibility varies by state, the picture will be considerably different for Kentucky, since families in this state are eligible for Medicaid up to about 60 percent of the poverty line compared to Arkansas's 17 percent, as indicated by the bottom segment of the chart.

The chart shows that if Kentucky were to reject expansion, people with incomes from the poverty line down to 60 percent of the line would not be eligible for any government coverage or assistance.

For a larger version of the chart and a clear look at a complicated subject, click here.

Governors in both parties undecided on whether to expand Medicaid; seeking answers to several questions

There is hesitation among governors on both sides of the aisle regarding whether or not to expand Medicaid, which would cover millions more Americans under the program for the poor and disabled.

"At least seven Democratic governors have been noncommittal about their willingness to go along," N.C. Aizenman and Karen Tumulty report for The Washington Post. Gov. Steve Beshear has not indicated whether he will expand coverage in Kentucky, but previously expressed concerns about the costs associated with the move, and state House Republican Leader Jeff Hoover has said he should not. Kentucky would have to start paying part of the extra cost in 2017, and 10 percent of it by 2020. Several Republican governors have said they will not participate, while others say they have not decided.

The issue is surely a major discussion topic at the National Governors Association meeting this week in Williamsburg, Va. Questions remain unanswered: "Will states that opt in have the option of scaling back in future years? If a state that opts out decides it wants to participate at some later point, will the federal government still pay nearly the full cost of covering those who become newly eligible for Medicaid? And can a state participate only partially — for instance, by raising the income cutoff for its program to a level lower than the ceiling envisioned in the law, which is set at 133 percent of the federal poverty line?" Aisenman and Tumulty ask.

NGA Executive Director Dan Crippen said states are confused over what to do. The association has sent a list of questions to Secretary of Health and Human Services Kathleen Sebelius about the issue. "States need to be making these decisions now, and it's hard to make them if you don't have clarity," said Matt Salo, director of the National Association of Medicaid Directors.

Sebelius has said she will address concerns during meetings that will take place in various cities starting July 31. There is no deadline yet for when states must choose whether or not to expand. (Read more)

Repeal of health law would have big impact on Kentucky, HHS Secretary Sebelius writes

The U.S. House voted again yesterday to repeal the health-care reform law, a move that has no chance of passing in the current Senate and would be vetoed by President Obama if it did.

In an op-ed piece in The Courier-Journal, which put the news of the House vote on an inside page, Health and Human Services Secretary Kathleen Sebelius, left, said a repeal of the law would have big ramifications for Kentucky because:

• The law eliminates lifetime limits on coverage because it prevents insurance companies from dropping customers if they get sick or meet a lifetime dollar cap. This had helped 1,414,000 Kentuckians, including 528,000 women and 362,000 children.

• It provides free preventive care like vaccinations, checkups and cancer screenings for 732,000 Kentuckians who have private health insurance.

• It provides funding for expanding community health centers in underserved areas.

• It requires insurance companies to spend "at least 80 cents of every premium dollar on health care and quality improvements, not CEO salaries or advertising," Sebelius writes. If they don't do so, customers get a rebate.

• Seniors receive free preventive services under Medicare, and the law eliminates the prescription-drug "doughnut hole." Since the law was enacted, 5.2 million Medicare beneficiaries have saved more than $3.7 billion on prescription drugs.

• The law allows young adults up to age 26 to remain on their parents' insurance plan, which translates to 48,000 Kentuckians. (Read more)

New form of Oxy is harder to inhale and inject, so drug users are turning to heroin, Opana for high

A new formulation of OxyContin makes it harder to
inhale or inject. Drug Enforcement Administration photo.

A change in the formulation of the powerful drug OxyContin has addicts turning to another high to fuel their habit: heroin.

Researchers at the Washington University School of Medicine in St. Louis had more than 2,500 patients from 150 drug rehabilitation treatment centers in 39 states respond to survey questions that had a particular focus on the reformulation of OxyContin, reports research-reporting service Newswise. The new formula makes it harder to crush the pills, making inhaling or injecting them more difficult.

Since the new version of the drug was introduced, "inhalation or intravenous administration has dropped significantly," said lead investigator Theodore J. Cicero. But drug use has not lessened, with addicts turning to heroin instead, which is also inhaled or injected. "We're now seeing reports from across the country of large quantities of heroin appearing in suburbs and rural areas," Cicero said.

OxyContin was originally designed to be released in the body slowly, preventing an immediate high. But by crushing the pills and inhaling them or dissolving them in water and then injecting the solution, addicts were able to get "an immediate rush," Newswise reports.

Moreover, because OxyContin was designed to be slow-release, it contained large amounts of the generic drug oxycodone, which spurred even more in demand. The new version of the drug was introduced in 2010.

Survey results show "users who selected OxyContin as their primary drug of abuse has decreased from 35.6 percent of respondents before the release of the abuse-deterrant formulation to 12.8 percent now," Newswise reports. (Read more)

The Centers for Disease Control and Prevention has called prescription drug abuse an "epidemic." In Kentucky, about a 1,000 people die each year from prescription drug overdoses. More people die in Kentucky from prescription drug overdoses than they do from traffic accidents.

Law enforcement is also seeing that drug seekers are switching from OxyContin to the prescription drug Opana, reports Donna Leinwand Leger for USA Today. "A few years ago, it was OxyContin. Now it's Opana," said Raquel Foster, a police spokeswoman for the Fort Wayne Police Department.

As a new, harder-to-abuse formulation of Opana hits the market, however, "they are going to find a way to satisfy their addiction," said DEA Special Agent Gary Boggs of the Office of Diversion Control. "When they either can't get those particular pharmaceuticals or can't afford them, they now gravitate to heroin."  (Read more)

Work of UK prof was cited in decision on health care

Professor Nicole Huberfeld.
University of Kentucky photo.

The work of a University of Kentucky law professor helped shape the U.S. Supreme Court's ruling on the constitutionality of the federal health-care reform law. 

Two of the major issues in question was whether the government could be force people to buy health insurance — often referred to as the individual mandate — and if the federal government could use its fiscal powers top make states expand Medicaid eligibility to 133 percent of the federal poverty level. The mandate was upheld, as was the Medicaid expansion, though the ruling will allow states to choose whether or not they want to expand their programs.

Justice Ruth Bader Ginsburg cited the work of UK professor Nicole Huberfeld "in a portion of her concurring opinion dealing with the expansion of Medicaid," reports Brian Powers for Business Lexington. In her work, Huberfeld has focused on the program for the poor and disabled and had researched "the intersection of constitutional law and health-care law," Powers reports.

When Huberfeld was told her work had been cited she said it was "amazing," as well as "thrilling ... humbling." She added, "We sometimes feel that we perform our research and publish it and get it out there, and to know that someone is actually reading it is really gratifying. When you write, you hope that someone reads your research." (Read more)

Legislators, doctors debate how health law will or should affect Kentucky; we answer some questions that were left hanging

By Tara Kaprowy and Al Cross
Kentucky Health News

Though host Bill Goodman (above, in an advance promo) said they just "scratched the surface" on what the federal health-care reform law will mean for Kentucky, physicians and legislators debated Medicaid expansion, the implications of requiring people to buy health insurance, how to pay for it all and other questions last night on KET's "Kentucky Tonight" panel and call-in show.

Perhaps the biggest question about the law in Kentucky is whether the state will choose to expand Medicaid, allowing as many as 329,000 more people with incomes up to 138 percent of the federal poverty threshold to qualify for the program for the poor and disabled and be paid for entirely by the federal government in 2014-16. State Rep. Mary Lou Marzian, D-Louisville, pushed hard for the expansion, saying "We can't leave 100 percent of the money laying on the table."

Starting in 2017, the amount of federal contribution will start to decrease — to 95 percent in 2017, 94 percent in 2018, 93 percent in 2019 and 90 percent in 2020 and subsequent years, according to the Henry J. Kaiser Foundation.

Kentucky already has a $400 million shortfall in its budget, said Republican state Sen. Tom Buford of Nicholasville, and would need "$515 to $695 million by 2020" to pay for the additional recipients. Other Republicans have said that would require higher taxes or cuts in services, and called for Gov. Steve Beshear to reject the expansion, but supporters of the law argue that the state will save money overall. For that story, click here.

Louisville urologist Michael Macfarlane, a member of the state Republican executive committee, said he would like to see everyone get health care, but "It really boils down to how are we are going pay for this. . . . In every program like this they underestimate what the future entails. . . . The money is not out there. . . . We are going to be Greece and Spain before long."

Marzian replied, "We are paying now for our uninsured folks that we can put onto Medicaid." Noting that the state has spent hundreds of millions of dollars to help the Kentucky Speedway and the Kentucky Horse Park and build the Yum! Center in Louisville, she asked, "Why can’t we help our middle class and the poorest of the poor get health insurance and health care?" She said the law will stimulate the economy because having more people insured will generate more need for health-care services and health-care jobs.

The panel also debated the implications of the law's requirement to buy health insurance or pay a penalty, which the U.S. Supreme Court upheld as a legitimate use of the taxing power of Congress. Marzian said requiring people to buy health insurance is "personal responsibility" since "everybody uses health care at some point."

Buford, an insurance agent and the chairman of the Senate Banking and Insurance Committee, contended that instead of buying health insurance, those not eligible for Medicaid could just choose to pay the penalty ($695 for individuals or up to 2.5 percent of the household income, the Kaiser Foundation notes) and when hospital care is needed, "She can buy insurance on her way in the ambulance," and after being treated, can cancel the policy.

"That is simply not true," Marzian said. "There is a waiting period." Well, not exactly.

Nicole Huberfeld, a University of Kentucky law professor whom Supreme Court Justice Ruth Bader Ginsburg cited in her opinion, told Kentucky Health News, "The law allows for one three-month grace period of non-coverage per year, so if a person were uncovered, then covered, then uncovered, then covered, penalties would be assessed for the second two non-covered periods." She called that scenario "economically inefficient" since "Most people do not choose to pay something, the tax penalty, for nothing: opting not to have insurance coverage."

In his blog for MoneyTalks News, Stacy Johnson argued that buying health coverage only when it's needed might also backfire: "If you go to the emergency room for a broken leg, will you sit there in agony, applying for insurance and waiting as long as it takes for newly purchased insurance to kick in?"

The liveliest debate on the hour-long show was between the two doctors, Macfarlane and Morehead internist Ewell Scott.

Macfarlane said, "This system really has nothing to do with helping people get health insurance, this system is really going to take over health care . . . directly by computer programs and protocols out of Washington," which he said will ration care and socialize the system. He said a new coding system that will require physicians to select from a vast number of codes — up to 68,000 in the new system from 13,000 in the old one, the American Medical Association indicates — to describe in detail the diagnosis and treatment of each case.

Scott replied, "I think Dr. Macfarlane, with all due respect, is crazy. . . . This is not going to happen." Asked is and how Macfarlane was misstating the facts, Scott said, "This is not going to be a problem for the physician." Macfarlane replied, "That's just not true."

The system in question is the International Classification of Diseases. The ninth version of the system has been in place for 30 years. The transition to ICD-10 will be effective Oct. 1, 2013, according to the Cabinet for Health and Family Services. Despite the increased number of codes, it is not expected to be more time-consuming for providers because "each diagnosis or procedure gets only one code," said Don McLeod, spokesman for the federal Centers for Medicare & Medicaid Services.

Scott acknowledged the law is not perfect and "does nothing to control costs in the long run," but called it "a baby step forward for getting us out of this terrible, dysfunctional health-care financing system we've gotten ourselves into." Scott noted the U.S. has the most expensive health-care system in the world "by double" but has "the worst outcomes in the world." A study by The Commonwealth Fund ranked the U.S. sixth of the seven main industrialized countries in terms of quality.

Macfarlane maintained, "We have the best system in the world." He acknowledged changes are needed, but "The idea that the mandate will pay for this is just false." Large swaths of the population, including young adults, undocumented immigrants and people who are out of work, will continue to avoid buying health insurance, he said. (In fact, undocumented immigrants are exempt from paying the penalty, according to the Kaiser Foundation.)

Goodman ended the show by acknowledging the subject's complexity and the need for more discussion on another episode later this summer or in early fall. To view the show, click here.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Expanding Medicaid will save the state money by eliminating much expense on the uninsured, think tank and op-ed writer argue

If Kentucky chooses to expand Medicaid eligibility up to 133 percent of the federal poverty level, the state will gain in key areas, argues Jason Bailey, director of the Kentucky Center for Economic Policy, right, in an op-ed piece in the Lexington Herald-Leader.

Citing numbers from the Urban Institute, Bailey said the law will provide more than 400,000 Kentuckians with health insurance whether through the expansion of Medicaid or through the state insurance exchange, a number he told Kentucky Health News is a "conservative estimate."

But the kicker is the move will also "result in deep savings in money now spent on the uninsured," he writes. Bailey again quotes from the Urban Institute report, which indicates the state will save between $140 million and $828 million in the first six years of the law in large part because of the decreased use of emergency rooms and because Medicaid will pick up most of the tab for mental health services, which states and local governments mostly shoulder alone.

The Center on Budget and Policy Priorities, though, estimates that states' Medicaid spending will rise by 2.2 percent by 2022 if they decide to expand Medicaid. But that number "actually overstates the net impact on state budgets because it does not reflect the savings that state and local governments will realize in health-care costs for the uninsured," CBPP spokesperson Shannon Spillane told Suzy Khimm for The Washington Post. "In fact, states could end up with a net gain." (Read more)