Wednesday, March 20, 2019

Governor says he exposed his 9 children to chicken pox, says vaccines aren't for everyone; expert says we're not in 17th century

https://www.courier-journal.com/story/news/politics/2019/03/20/matt-bevin-exposed-kids-chickenpox-instead-vaccine/3221848002/
For a recording of this part of Bevin's interview with WKCT Radio in Bowling Green, click here. A full Kentucky Health News story will appear later.

Bill on Bevin's desk would require a malpractice lawsuit to certify that an expert has said it has a reasonable basis to be filed

By Melissa Patrick
Kentucky Health News

A bill to require anyone filing a lawsuit against health-care providers to get a qualified expert to declare that the case has merit has passed the General Assembly and awaits the signature of Gov. Matt Bevin.

Rep. Chad McCoy
House Bill 429, sponsored by Rep. Chad McCoy, a plaintiffs' lawyer from Bardstown, would require plaintiffs in most medical-malpractice lawsuits, including those against long-term care facilities, to file a "certificate of merit," defined as "an affidavit or declaration" saying that the case has been reviewed by a qualified expert who says "that there is reasonable basis to commence the action."

When presenting the bill to the House on March 1, McCoy, who is also the Republican whip, said all the lobbying interests on the malpractice-claims issue came to the table after the Kentucky Supreme Court struck down a 2017 law that required such claims to go before medical review panels before proceeding.

Chief Justice John Minton wrote in the court's decision, “Of all the rights guaranteed by state constitutions but absent from the federal Bill of Rights, the guarantee of a right of access to the courts to obtain a remedy for injury is possibly the most important.”

When the 2017 law passed, McCoy warned his colleagues that it wasn't constitutional, and suggested that the state instead require merit certificates or affidavits. This year, he told them the bill, if passed, would help to stop frivolous lawsuits. Earlier, he told the House Judiciary Committee that the bill was supported by the Kentucky Chamber of Commerce, the nursing-home association and the trial attorneys, and that the Kentucky Hospital Association was neutral.

The bill passed the House 69-24 on March 1 and the Senate 37-0 on the consent calendar that is used to pass bills without debate.

The bill has exceptions. It says a certificate isn't required if "the consultation could not reasonably be obtained" before the deadline to file a suit; if "the claimant or his or her counsel had made at least three separate good-faith attempts with three different experts to obtain a consultation and that none of those contacted would agree to a consultation, so long as none of those contacted gave an opinion that there was no reasonable basis to commence the action;" or if the plaintiff "intends to rely solely on one or more causes of action for which expert testimony is not required," including claims of lack of informed consent or the legal doctrine that says an accident implies negligence.

Cincinnati opens a pilot program to get immediate help for people who want help with addiction


Cincinnati has started a pilot program that lets people who are seeking addiction treatment get it by simply walking into one of their six participating health centers, Terry DeMio reports for the Cincinnati Enquirer. The "Safe Places Cincy" pilot was announced on Monday.

"We have a very narrow mission," Dr. O'dell Owens, president and CEO of Interact for Health, a foundation supporting the program, told DeMio, who has been covering the issue for years. "We are another point of contact (for the addicted) exactly when they need it."

DeMio reports, "Safe Places Cincy works like this: If you want addiction treatment, go to a Cincinnati health center and ask for it. Once there, a 'strike force team' will figure out whether you need hospitalization. If so, they'll get you to the hospital. If not, they’ll connect with one of three partnering addiction centers: Talbert House, Brightview Health or the Center for Addiction Treatment, to secure an appointment. After that, they’ll call Uber Health for a ride to the center if it's open. If not, they'll get you to a safe place to stay. When the treatment site opens, Uber Health will take you there."

Cincinnati Health Commissioner Melba Moore told DeMio that this is "a natural" fit for the health centers: "This is a public health issue. This is what we should be doing in our health centers."

Cincinnati City Council Member Amy Murray, who partnered with health officials and organizations to create the program, told DeMio that it is modeled after one in New Hampshire called Safe Station, which uses fire stations for those who seek addiction treatment.

The Manchester, N.H., fire chief says its program has been in place since May 2016 and has been used as an access point 5,221 times, or roughly five times a day, DeMio reports.

DeMio writes that Cincinnati Fire Department officials weren't entirely comfortable with spearheading the program, so organizers took a different approach, using the health centers. She adds that Interact for Health provided a $10,000 grant for the Uber Health account.

The advantage to using fire departments is that they are open 24/7, while health centers are only open during the day. But the hope is that after the year-long pilot program is up, Safe Places Cincy will find a partner that is open round-the-clock, DeMio reports. Click here for the health centers' addresses and contact information.

UK welcomes 90 scholars from 50 nations for seminar on addiction; 3 events open to public Thur. and Fri. mornings

Beth Macy, author of Dopesick, will give the
keynote plenary address at 8:30 a.m. Thursday.
Ninety Fulbright scholars from about 50 countries are gathering at the University of Kentucky today to attend the Fulbright Visiting Scholar Enrichment Seminar: Combating Addiction, which runs through Saturday. Several events will be open to the public.

The seminar is hosted by UK's International Center in cooperation with the Institute of International Education and the U.S. Department of State’s Bureau of Educational and Cultural Affairs.

It will address various aspects of addiction, including interdisciplinary research, education, clinical and community outreach practices relating to substance use disorders and recovery.

Beth Barnes, professor in the College of Communication and Information and co-organizer of this event, said it will provide opportunities to examine the crisis of addiction “through the lenses of medicine, social constructs, policy, government and the legal system and NGO interventions."

The public events are:
  • 8:30 a.m., March 21 at the Gatton Student Center Worsham Cinema: Keynote plenary address by Beth Macy, journalist and bestselling author, who addressed America’s 20-plus year struggle with opioid addiction in her latest book, "Dopesick: Dealers, Doctors, and the Drug Company that Addicted America." Macy will focus on  the trajectory of opioid addiction in the southeastern U.S. Following the keynote, attendees will be given the opportunity to purchase the book and meet Macy.  ​
  • 11 a.m.-noon March 21 in Worsham Cinema: Screening of the "The Narcotic Farm," an  award-winning documentary about the U.S. Bureau of Prisons facility on Leestown Road in Lexington, where almost every arrested addict between 1935 and 1975 was sent for a cure. 
  • 9-10:30 a.m. Thursday, March 22 in the Worsham Cinema: Plenary session by John C. Tilley, secretary of the Kentucky Justice and Public Safety Cabinet, who will be speaking on “Public Policy, State and Federal Intervention Approaches to Combating Addiction.” 
Also, on March 28, the UK Office of Institutional Diversity will host a related talk on the issue of opioid addiction in America by Sam Quinones, journalist and author of Dreamland. This event is also open to the public and will begin at 10 a.m. in the Gatton College of Business and Economics.

Tuesday, March 19, 2019

County Health Rankings show a few big shifts, and at least one county where local action appears to have made a difference

By Melissa Patrick
Kentucky Health News

Some Kentucky counties that are actively working to improve their community health made significant gains in the latest County Health Rankings issued by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

The rankings measure health outcomes, gauged by life expectancy and measures of quality of life; and health factors, such as access to physicians and areas to exercise, tobacco use, children living in poverty, violent crime, long commutes and other environmental factors.

Clinton County, in Appalachian Southern Kentucky,  moved up 30 notches in health outcomes, to 64th from 94th among Kentucky's 120 counties. Pendleton County, in Northern Kentucky, went up 31 slots, to 25th from 56th. Lyon County, in Western Kentucky, rose to eighth from 38th.

Clinton County has ranked in the bottom fourth of counties for health factors and outcomes for many years. It moved up only five slots, to 90th, for health factors, but its big gain in outcomes was significant.

The improvements could be an indication that the efforts of the Clinton County Healthy Hometown Coalition that was created in 2013 are beginning to pay off. The coalition, which was created with the help of a grant from the Foundation for a Healthy Kentucky, has largely focused on efforts to improve the health of the county's children, such as building walking paths and playgrounds as well as working to increase physical activity and nutrition programs in the schools, which banned tobacco.

"The Clinton County coalition is a great example of community coming together to identify a significant local health issue and develop a comprehensive plan to make actual, measurable improvements," said Ben Chandler, president and CEO of the foundation. "Members represent a broad cross-section of the community. That's essential to developing and implementing programs that address the myriad factors that affect health."


Most counties' changes were insignificant; the rankings compare a state's counties against each other without national comparisons, so when one moves up, another moves down.

In health outcomes, 19 counties moved up at least 10 notches since last year, and another 14 moved down by at least 10. In health factors, about 12 counties improved at least 10 notches and 11 dropped by at least 10.

Because the shifts in the rankings for most counties are so small that they are statistically insignificant, the researchers have placed counties in four groups of 30 counties, called "quartiles."  The rankings are meant to be viewed more as a general categorization of a county's health status, rather making specific comparisons with counties that are relatively close in the rankings.

The bottom quartile for both health outcomes and factors continues to be almost entirely Appalachian. The only exceptions for health outcomes are Fulton County, in the Mississippi Delta at the state's western tip, and Carroll County, between Louisville and Cincinnati. The exceptions for health factors are Fulton County and Grayson County, in west-central Kentucky.

Oldham and Boone, two of Kentucky's wealthiest counties, continue to be the top two for health outcomes, as they have been since the rankings began in 2011. No. 3 Shelby County, which borders Oldham, has been in the top five since 2013. Adjoining Spencer County is ranked fourth. Calloway County (Murray) in Western Kentucky took the fifth spot this year, replacing Bullitt County, which dropped to No. 9.

Oldham and Boone are also the top two counties in health factors, and have been since 2015. They have been in the top five since 2011. Woodford, Campbell and Scott are currently ranked third, fourth and fifth, respectively.

Owsley, Perry, Breathitt, Bell and McCreary counties, in that order, are the bottom five in outcomes. All are in the Eastern Kentucky Coalfield. Wolfe County, which has been in the bottom bunch since 2016, moved to No. 113, an insignificant change. The bottom five counties for health factors are Clay, Owsley, Harlan, Lee and Wolfe, all in the eastern coalfield.

Some counties show big changes

Several counties moved up more than 10 notches to make it into the top quartile for health outcomes. Hickman County, the only Kentucky county that borders Fulton County, moved up 26 slots to rank 17th. Edmonson County moved up 15, to rank 18th; Logan moved up 18, to 22nd; and McCracken (Paducah) moved up 21, to 26th.

Two counties dropped more than 10 slots to land them into the bottom quartile for health outcomes: Lewis is now 92nd, down from 74th last year, and Wayne is 91st, down from 77.

Two counties moved up more than 10 slots to make it into the top quartile for health factors: Bourbon, which moved to 28th from 51st, and Caldwell, which moved to 29th from 56th.

Carter County was the only one to drop more than 10 slots to fall into the bottom quartile for health factors, to 97th from 76th.

Livingston County saw the greatest drop in health outcomes this year, falling 42 notches, to 76th from last year's 55th. It also dropped 25 slots in health factors, to 65th.

McLean County also saw a big drop in outcomes, falling 38 slots to 73rd. It dropped 21 slots in factors, to 56th.

Tiny Robertson County saw the greatest improvement in health factors, moving to a 36th from 75th last year. However, it saw an eight-notch drop in health outcomes, to 96th.

Bracken County, after dropping 43 notches for health outcomes in last year's rankings, dropped yet another five slots to rank 103rd. And while it has hovered between 32nd and 43rd for health factors since 2014, it dropped 27 slots in this year's rankings, to 60th.

Another county that saw big drops in both outcomes and factors is Carlisle, just north of Hickman on the Mississippi. It had a 29-notch drop in outcomes, to 52nd, and a 14-notch drop in factors, to 41st. From 2014 to 2018, Carlisle had ranked between 21st and 27th for health factors.

For a table of counties with big changes, click here.

The report charges Kentucky counties to take this data and turn it into action, and offers specific strategies to do so on the "Take Action to Improve Health" section of its website. These strategies include, among other things, a link to evidence-informed policies and programs that are proven to work locally in the "What Works for Health" section.

Further, the measures in the rankings offer journalists a unique opportunity to see what is going on in their communities when it comes to health -- both good or bad. And many Kentucky newspapers do just that.

In 2017, an analysis by researchers at the Institute for Rural Journalism and Community Issues at the University of Kentucky found that 31 papers in 30 counties published 36 separate articles about the rankings in the five weeks after the rankings were released in late March. The researchers examined 106 of the approximately 140 paid-circulation newspapers outside Kentucky's three major urban areas, covering 115 of the state's 120 counties.

Saturday, March 16, 2019

Bill to certify Ky. midwives OKd after years of effort, and changes that got doctors and hospitals to end longstanding opposition

By Melissa Patrick
Kentucky Health News

Loud clapping and shouts of joy filled the state House chamber March 13 when a bill to give certified midwives professional recognition in Kentucky passed after many years of work by lawmakers and advocates.

Midwives and their advocates gathered for a photo after the March 6 House
Licensing, Occupations &Administrative Regulations Committee meeting.
Photo: Mhari Shaw, photojournalism student, Western Kentucky University
“This is not a bill about whether or not to allow home births; those are going to happen. This is a bill about making sure families who choose home birth have access to safe and competent care providers,” said Rep. Russell Webber, R-Shepherdsville, who presented Senate Bill 84 in the House.

The bill was the fourth attempt by Sen. Tom Buford, R-Nicholasville, to certify midwives. Several others had tried before him, but until this year they were met with strong opposition from the Kentucky Hospital Association and the doctors' lobby, the Kentucky Medical Association.

But both those groups, and the American College of Obstetricians and Gynecologists, went neutral on the bill after the House changed this year's version to require collaboration between midwives and health providers, rules for handling medium- and high-risk births, and an advisory council to recommend regulations to the Kentucky Board of Nursing.

Some of the council's recommendations will include guidelines for use of medications, ordering of medical tests, and policies for transfer to hospitals when necessary, Webber said.

As the bill went to the House committee, Weber told Kentucky Health News that midwives and consumers had been persistent in their efforts to educate legislators about what they do. "I almost liken this effort to a David versus Goliath situation," he said.

Rep. Chad McCoy, a Republican lawyer from Bardstown, added an amendment that would assure that no health-care provider would pick up any liability because of a midwife, and that each person involved in the care of a patient would be responsible for his or her own negligence.

Upon final passage of the bill, Sen. John Schickel, R-Union, chair of the Senate Licensing, Occupations and Administrative Regulations Committee, noted that the panel had often heard such bills. He said passage was the result of a long effort that had been contentious at times, though everyone involved continued to work toward the best outcome.

"This is really a historic day I think for health care, for the midwives, for a new day, [and] for the children of Kentucky," he said.

The changes the House made to the bill even allowed Republican Sen. Ralph Alvarado, a doctor from Winchester, to vote yes, after being one of its loudest opponents in prior years and voting no on the original version.

The bill passed on a vote of 96-1 in the House, with only Rep. Kim King, R-Harrodsburg, voting against it. The Senate concurred with the changes the next day on a 35-1 vote, with only Sen. Stan Humphries, R-Cadiz, voting against it. The original Senate vote on Feb. 21 was 32-4. The bill now moves to Gov. Matt Bevin for his signature or veto.

Buford said when presenting the bill to the Senate in February, “This is a personal choice made by these families for various reasons. We must ensure the families who choose this option have access to quality care through … the licensing of midwives.”

As it stands, Kentucky has no rules or regulations for midwives. When presenting the bill on March 6 in the House committee, Buford said, "Believe it or not, I could be a midwife today, and I know nothing about it."

Mary Katherine DeLodder, a leader of the Kentucky Home Birth Coalition, told the committee that the bill is about legitimizing midwifery, since right now you don't know what you are getting when you hire a midwife and communications about them are typically shared via social media. "It's like you have to know the secret handshake sometimes to find your midwife," she said.

She said Kentucky has about 700 home deliveries a year, and 33 states already have certified professional midwife programs. A letter on the coalition's website about the bill's passage says Kentucky has about 20 certified professional midwives.

Elizabeth Regan, president of the Kentucky Chapter of National Association of Certified Professional Midwives, told Kentucky Health News that SB 84 was about access to midwifery care: "This is what we know makes home births safe, integration into the larger health care system and building collaborative relationships."

Friday, March 15, 2019

Legislature passes four abortion bills in last days of session, likely to pass one more; federal judge blocks two of them (updated)

Gov. Matt Bevin, shown speaking at a Right to Life event, is taking credit for the legislative action.
By Melissa Patrick
Kentucky Health News

Since Republicans took complete control of Kentucky lawmaking in 2016, the General Assembly has passed several bills to restrict or eliminate abortion, and this year is no different. Four anti-abortion measures passed in the last days of the session and one more is likely to pass on the final day, March 28.

The bills take several measures to limit or monitor abortions in Kentucky, but the centerpiece is one that would ban abortion once a fetal heartbeat is detected, around six weeks of pregnancy.

Part of the impetus for that bill is the hope that two new Supreme Court justices could lead to the reversal of Roe v. Wade, the court's 1973 decision creating a limited constitutional right to abortion.

The legal process quickly followed the legislative process. Immediately after Gov. Matt Bevin signed one bill into law, the American Civil Liberties Union of Kentucky filed a lawsuit on behalf of EMW Women's Surgical Center in Louisville, the state's only remaining abortion provider.

Hours later, U.S. District Judge David Hale of Louisville granted the ACLU's request for a temporary restraining order blocking enforcement of the law banning abortion of a fetus with a beating heart.

"The heartbeat is the first sign of life and it is the last thing that you will hear when a person dies," Rep. Chris Fugate, a Republican from Chavies in Perry County, said on the House floor as he managed Senate Bill 9, sponsored by Sen. Matt Castlen, R-Owensboro, to passage on a 71-19 vote.

One of the "no" votes came from Democratic Rep. Chris Harris of Pikeville, who described himself as pro-life. He said the bill's constitutionality had already been decided, the state was already a defendant in three other lawsuits over other abortion bills, and "We have a responsibility to the people to not waste their money."

The ACLU says every "heartbeat" bill passed to date has been overturned in state or federal court. Kentucky is the second state this year to enact such a near-total ban on abortion, but the first to take effect, because SB 9 had an emergency clause. Mississippi's law will go into effect July 1. (Rewire.News offers a legislative tracker for abortion bills in the 50 states.)

Opponents of "heartbeat bills" say they are unconstitutional, near-total bans because most women don't know they are pregnant until after six weeks of pregnancy, and ultrasounds to determine the health of a fetus aren't typically done until the 14th week of pregnancy.

"There are no exceptions for rape, incest, fetal anomalies, or if there is a tragic condition with the fetal anomalies," said Tamarra Wieder, the public affairs and policy director for Planned Parenthood of Indiana and Kentucky.

The bill passed the Senate 31-6 on Feb. 14. The House rejected an amendment from Rep. Jason Nemes, R-Louisville, that would have allowed abortion of a fetus that was medically determined to be incompatible with life outside the womb.

Rep. Robert Goforth of East Bernstadt, who is challenging Bevin in the May 21 Republican primary for governor, filed a measure similar to SB 9, House Bill 100. "My bill's been held hostage and passed over and not heard because of politics," he told the House as he supported SB 9.

Bill would ban discriminatory abortions

The other bill targeted by the ACLU lawsuit, and the first of the four to pass, would ban abortion for women seeking to terminate a pregnancy because of an unborn child's sex, race, color, national origin or the diagnosis or potential diagnosis of Down syndrome or any other disability.

House Bill 5, sponsored by Rep. Melinda Gibbons Prunty, R-Greenville, passed the House Feb. 26 on a 67-25 vote and the Senate March 13 by 32-4. It will become became effective immediately upon Bevin's expected signature March 19. He published an article March 11 saying that the effort to pass anti-abortion bills was led by his administration. UPDATE, March 20: Judge Hale issued a temporary restraining order blocking the law.

Prunty told the House that HB 5 is a "common sense" measure because allowing abortions for any of these reasons is "reminiscent of the social evil of eugenics," the science of improving a human population by controlled breeding to increase the occurrence of desirable, inheritable characteristics.

Sen. Ralph Alvarado of Winchester, who presented the bill in the Senate, repeated that point, which Bevin has also made. Alvarado is Bevin's running mate for lieutenant governor.

Sen. Reginald Thomas, D-Lexington, unsuccessfully offered an amendment for lifetime coverage of medical expenses for children born with certain disabilities. He said, “I cannot comprehend how we want to bring life into this world with a child who has the disabilities I have enumerated, and then abandon that child once that child comes into this world.”

ACLU spokeswoman Brigitte Amiri said in a press release on the bill, “Decisions about whether to end a pregnancy must be made by the woman and her family. But this law takes the decision away from them and hands it over to politicians. Kentucky women must be able to have private conversations with their health-care providers, and must be able to decide whether to have an abortion.” She said the bill is part of a campaign to ban all abortions.

Other bills

House Bill 148, sponsored by Rep. Joseph Fischer, R-Fort Thomas, would ban all abortions in Kentucky if the Supreme Court overturns Roe v. Wade. It passed the House with Feb. 15 on a vote of 69-20 and the Senate on March 14 by 32-5.

Such bills are called "trigger bills" because the legislative action would take effect only constitutional law changes. The ACLU says "trigger laws" have been filed in seven states this year.

Fischer told the House, “Abortion is not a divisive issue in this state; the people of Kentucky are overwhelmingly against abortion. House Bill 148 will serve as a message from the people of Kentucky to the Supreme Court and every other state ... if you allow us to protect life, we will protect all unborn life.”

But freshman Rep. Patti Minter, D-Bowling Green, said the bill was premature. “It does nothing to advance any policy objectives,” she said. “We should not be in the business of passing a bill now that may or may not be valid, depending on what might or might not get handed down by the Supreme Court.”

Senate Bill 50, which would require health-care providers to report any prescriptions used to induce an abortion to the state Vital Statistics Branch, is also on its way to Bevin, with an amendment that would require providers to tell patients who take these medications that the abortion can be reversed — information that the American Congress of Obstetricians and Gynecologists says in an August 2017 fact sheet is "unproven and unethical."

The bill, sponsored by Sen. Robby Mills, R-Henderson, passed the House 75-19 on March 13. The next day, the Senate accepted the amendment and passed the revised bill 31-4. The vote on the original bill, in January, was 30-6.

"With the passing of these four bills, we basically now have zero access and zero exemptions," Wieder, of Planned Parenthood, said Friday. "What we saw on the floor last night was simply callous, to deny even exemptions for families where the fetus will not survive to birth and there cannot be any exemptions even for their circumstances. I think that actually speaks to all of these bills, especially Senate Bill 9, that there is no concern for the lived experiences of women and families in the Commonwealth."

Still pending is Senate Bill 227, sponsored by Sen. Whitney Westerfield, R-Hopkinsville. It would require physicians to try to save the life of an infant born alive after a failed abortion attempt. It is similar to the federal "Born Alive Infant Protection Act," which failed in the U.S. Senate last month.

Westerfield's bill passed the Senate Feb. 28 on a 32-0 vote and could pass the House on March 28, the day set aside for reconsidering bills Bevin may veto — or bills that he wouldn't.

Wieder said the bill isn't necessary because "there is no such thing as abortion after birth. . . . This is not medical practice." But she voiced concern that the bill would require life-saving care for babies who are not expected to survive, regardless of parental wishes.

Bevin's role

Wieder said of Bevin, "He is using rhetoric to stir up emotion and anger and fear out of a place that is not even from reality and that is a problem with so many of the conversations around abortion."

In his article, Bevin wrote, "As long as the Bevin administration exists, we will fight with all of our intellect, our talent, and our heart to defend the innocent. We will fight for life."

Citing the recent abortion laws passed in New York and Virginia, he wrote, "We now see that the true agenda of pro-abortion advocates across this nation is the mass murder of innocent babies, even after they have been born and are crying for their mothers" and that "pro-abortion radicals are even suing for the right to dismember a third-trimester baby."

Wieder said, "The idea that the bills in New York and Virginia somehow allow women and families to have an abortion up to or until a person gives birth is flat-out untrue. That's not how medical care works, and it's irresponsible to imply that. We all know that the vast majority of abortions occur very early in pregnancy and the ones that occur late in pregnancy are because of severe fetal anomalies, the baby won't survive out of womb or the woman is at risk. They are almost exclusively because the mother's health is at risk, a woman's life is at risk or the baby cannot survive."

Kentucky lawmakers have passed two abortion statutes that were recently struck down by federal judges: an old one that required abortion clinics to have signed agreements with a hospital and ambulance service, and a recent one to require providers to perform an ultrasound, describe it and show it to the patient prior to an abortion. The state is appealing both rulings.

A third case involves a 2018 law that would ban the most common type of abortion, known as "dilation and evacuation" at roughly 11 weeks of pregnancy or after. The case was heard in the U.S. District Court in Louisville last year and awaits a decision from the judge.

Judge in Medicaid work-requirements case seems skeptical that state and feds have come up with a plan that fits the law

The judge who kept Kentucky from adding work requirements to Medicaid last year remained dubious of the plan in a hearing on the latest attempt Thursday.

Judge James Boasberg (Law.com photo)
U.S. District Judge James Boasberg of Washington, D.C., "cast a seemingly skeptical eye Thursday as Kentucky and Trump administration officials sought to defend requiring some recipients to find jobs, volunteer or lose their benefits," Lesley Clark reports for McClatchy Newspapers. Boasberg asked the lawyers "why he shouldn’t again strike down the initiative, and whether it meets Medicaid’s objective to provide medical care."

The latter point was key to Boasberg's ruling last June, which struck down the Department for Health and Human Services' approval of the plan that was to take effect days later. The latest one is scheduled to take effect April 1, and Boasberg said he would rule by then.

"He also heard a challenge to work requirements imposed by Arkansas that have led to an estimated 17,000 losing coverage," Clark reports. The two cases crossed paths when Justice Department lawyer James Burnham "said that Kentucky wouldn’t know how many people would lose coverage until they started the program, Boasberg pointed to the loss of coverage in Arkansas.

Kentucky officials have estimated that under their plan, state Medicaid rolls would have 95,000 fewer people in five years than without the plan, called Kentucky HEALTH, for "Helping to Engage and Achieve Long Term Health." (Frequent references to that many people losing coverage are not precise, because tens of thousands of people go on and off the program each month.)

In his ruling last June, Boasberg, an appointee of President Barack Obama, ruled that HHS Secretary Alex Azar “never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.”

In both hearings, Boasberg questioned Burnham "on whether the work requirement plans approved by the Trump administration were helping to achieve Medicaid’s goal of promoting health coverage," Phil Galewitz reports for Kaiser Health News. "When Burnham argued that work requirements would give people incentives to find work and improve their lives, Boasberg interjected: 'That is not the purpose of Medicaid.' . . . Top health officials for the Trump administration have said getting people on Medicaid into jobs will make them healthier — which they call a key goal of the program."

Azar told the Senate Finance Committee Thursday that only 1,000 of those who lose coverage in Arkansas appealed, and “Only 1,452 of those 18,000 even reapplied for Medicaid when open enrollment came again.” He said that “seems a fairly strong indication” that the rest of those cut from the program “got a job and insurance elsewhere.”

In court, "Burnham argued neither Kentucky nor Arkansas was kicking people off their programs and causing them to lose benefits," Galewitz reports. "He said people were just choosing to not comply with the state’s new reporting requirements to show they were working, doing volunteer work or meeting one of the states’ exceptions."

"Boasberg questioned whether the state has proven its case to the federal government that it needs work requirements to keep its Medicaid program financially sustainable," Galewitz reports. Boasberg asked Burnham, “At the end of the day, isn’t the centerpiece of your case the fiscal sustainability argument?”

Republican Gov. Bevin has threatened to end his Democratic predecessor's expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level "unless his state is allowed to proceed with the new rules, a move that would cause the more than 400,000 new enrollees to lose their coverage," Galewitz reports. "He said the work requirement will help move some adults off the program so the state has enough money to help others on the program."

Ian Gershengorn, an attorney for the National Health Law Program, representing 16 Kentucky Medicaid beneficiaries, said the sustainability argument “seems absurd” because the federal government this year is paying 94 percent of Medicaid expansion costs," Galewitz reports: "He said HHS should not be approving Kentucky’s waiver based on the governor threatening to kill the entire Medicaid expansion if he doesn’t get work-requirement authority."

Lawyers for Bevin and the Trump administration "argued that any flaws he identified were addressed and the state is ready to roll out" the plan, Clark reports. Gershengorn "dismissed the changes and said they’d still result in an unacceptable loss of coverage."

The state and Azar have “worked exhaustively to minimize coverage loss,” argued Deputy General Counsel Matthew Kuhn, who "sported a bright red pin scissors pin, a symbol of Bevin’s signature Red Tape Reduction Initiative, as he argued his case," Clark reports. "He said the changes would exempt thousands from the work requirements."

Clark notes, "Kentucky was the first of four states to win federal approval to impose a work requirement for Medicaid enrollees, and the case has national implications with other states moving quickly to impose similar restrictions."

Thursday, March 14, 2019

Tobacco-free-schools bill, hotline to report use of electronic cigarettes in schools are on track to pass before end of session

By Melissa Patrick
Kentucky Health News

Two bills that address teenagers' tobacco use are still on track to become law, one to ban use of tobacco products at all Kentucky public schools and events, and another to create a hotline in schools for students to anonymously report the use and distribution of electronic cigarettes.

Bonnie Hackbarth of the Foundation for a Healthy Kentucky
and Rep. Kim Moser presented the tobacco-free school bill
House Bill 11, known as the tobacco-free school bill, was the only bill heard Thursday at a special Senate Health and Welfare Committee meeting. It passed unanimously, but needs one more day to become law.

Today is the legislature's last day before adjournment until March 28, when it will return to reconsider any bills vetoed by Gov. Matt Bevin. Sen. Ralph Alvarado, the committee chairman, said after the meeting that he was "cautiously optimistic" that the bill would pass the Senate March 28.

Alvarado, a Winchester physician who is Bevin's running mate for lieutenant governor, added that Bevin "has told me he would sign this bill. We just need to get it to him." The Senate passed a similar, stronger bill in 2017.

The bill, sponsored by Rep. Kim Moser, R-Taylor Mill, would ban the use of tobacco and electronic cigarettes on all school-owned properties and school-sponsored events on school properties. The bill does not prohibit the possession of tobacco and e-cigarette products, just the use of them. Enforcement would be left up to individual school boards. Smoking in schools is already banned.

"Modeling this positive behavior for students is critical, especially in schools," Moser told the Senate committee. "This creates an environment where tobacco use is not the norm."

Moser noted that there has been an explosion of electronic-cigarette use among teens, increasing 78 percent among high-school students and 48 percent among middle schoolers in the last year alone.

The bill had lingered on the House calendar for more than a month after unanimously passing the health committee, which Moser chairs, and was finally passed in the House on an 85-11 vote after getting two amendments to appease concerns about state-government overreach. One would give schools three years to opt out of the ban; the other would allow adults to smoke on field trips or at events off school property events when students are not present.

The Senate committee passed the bill unanimously, but not before Sen. Max Wise, R-Campbellsville, questioned who was going to be the "tobacco cop" in the schools. After voting yes, Wise said he'd like to check with school boards about the enforcement issue before the March 28 vote.

Moser has said that the bill has the support of the Kentucky School Boards Association and the Kentucky Association of School Superintendents. About 42 percent of the state's school districts ban the use of tobacco.

Bonnie Hackbarth, vice-president for external affairs with the Foundation for a Healthy Kentucky, told the committee that many of those districts have told her that with signage and messaging put out with the policy, it is often "self-enforcing."

For example, she said school officials in Bullitt County told her that they have created an educational card that they hand people when they politely tell them that the school's tobacco policy has changed to no longer allow use on school properties or school events.

"What we've been told over and over is that an educational approach is very effective," she said.

Students from Johnson County Middle School advocated a bill
to create a hotline for students to report concerns about vaping.
(Photos by Melissa Patrick, Kentucky Health News)
Senate Bill 218, sponsored by Sen. Brandon Smith, R-Hazard, passed unanimously out of the House Health and Family Services Committee, but was not placed on the consent calendar for bills that are passed without debate, after one committee member suggested that the topic was so important that it needed to be discussed on the House floor. It awaits final passage.

This bill would create an anonymous hotline or electronic system for students to report concerns about the distribution and use of e-cigarettes or other tobacco products on school property or at school events. It also includes an educational component and guidelines for how to handle the reporting.

Students from Johnson County Middle School presented the bill and suggested that the hotline be added to the anti-bullying hotline that should already exist in every school.

The students painted a vivid picture of the rampant in-school use of electronic cigarettes, which the seventh and eighth grade students only referred to as "juuling," referencing the most popular e-cigarette used by teens, made by Juul Labs.

The students said Juul products are easy to hide because they look like a large computer flash drive, that kids don't know that they have cancer-causing agents, and the devices' high nicotine content is causing children to become so addicted that they can't even make it through a class without going to the bathroom to use a device. One Juul pod has the equivalent of a pack of cigarettes.

One student said, "Today's kid who Juuls isn't the same kid who smoked cigarettes 30 years ago; it is the straight A student and the school athlete."

Asked if they were learning about the dangers of electronic cigarettes in their health classes, they replied in unison, "We don't have health classes."

Wednesday, March 13, 2019

Kentucky adults support syringe exchanges, 49% to 40%; among those who say they're familiar with them, it's 55% to 40%


Forty-nine percent of Kentucky adults continue to favor programs that allow people who use intravenous drugs to exchange used needles or syringes for sterile ones, while about 40 percent oppose such programs, according to the latest Kentucky Health Issues Poll.

The poll asked, “Some people favor needle exchange programs because they feel these programs help reduce the spread of AIDS. Others oppose needle exchange programs because they feel these programs send the message that it’s okay to use illegal drugs. What about you? Do you favor or oppose needle exchange programs?”

Kentuckians with more education, those who live in urban areas, and those aged 18 to 29 are most likely to favor needle or syringe exchanges. Generally, the more familiar they are with the exchanges, the more likely they are to support them as a strategy to reduce the transmission of HIV, hepatitis C and other viruses.


Among Kentuckians who said they were not very familiar, or not at all familiar, with the exchanges, support for them has increased since 2016, to the point that they are about evenly divided on the issue. Support may have decreased slightly among those with more familiarity, but the shift in those numbers was within the poll's margin of error for each number, 2.5 percentage points.

The Foundation for a Healthy Kentucky, which co-sponsors the poll, said in a press release that the stigma of drug use and addiction generates opposition to needle or syringe exchanges. That has occurred most often among county fiscal courts, whose approval is required for an exchange to open in a county. Approval is also required by the county health board and the council or commission of the city where the exchange is located.

"Needle exchange programs are about community safety and connecting people to treatment," said Ben Chandler, the foundation's president and CEO. "They don't lead to higher drug use, and they don't lead to more crime in the communities where they're located. We can't let false perceptions stand in the way of a proven strategy to help deal with Kentucky's opioid and meth crises."

The federal Centers for Disease Control and Prevention has identified 54 Kentucky counties most at risk from an outbreak of HIV or hepatitis C from intravenous drug use and dirty needles. Only 27 of those counties have syringe exchanges.
State Department for Public Health graphic; click on it for a slightly larger version
The state Department for Public Health website has information about the exchange programs.

"More than 50 needle exchange programs are operating in Kentucky, helping to reduce the chances of hepatitis C or HIV outbreaks that can put everyone in a community at risk," said Dr. Brent Wright, associate dean for rural health innovation at the University of Louisville. "These programs also remove dangerous used needles from the community, and can give participants access to vaccinations, substance-use-disorder treatment, overdose-prevention information and disease screening."

Wright was quoted in a press release from the foundation, which co-sponsors the poll with Interact for Health, a Cincinnati-area foundation. He is treasurer of the Kentucky foundation's board of directors.

Tuesday, March 12, 2019

House sends tobacco-free schools bill to Senate with three days left in session, minimum needed for passage; backers have hope

By Melissa Patrick
Kentucky Health News

A bill to make all Kentucky public schools and events tobacco-free passed the state House overwhelmingly Tuesday, but with just three legislative days left before adjournment, it needs the fastest possible track through the Senate, which passed a similar bill two years ago.

State Rep. Kim Moser
 (Legislative Research Commission photo)
House Bill 11 would ban the use of tobacco and electronic cigarettes on all school-owned properties, including all school events on such property. It does not prohibit the possession of tobacco and e-cigarette products, just use of them. Enforcement rules would be left up to individual school boards. It passed 85-11.

"Its purpose is to eliminate tobacco use during school hours and at after school events in order to help create an environment where tobacco use is not the norm," its sponsor, Rep. Kim Moser, R-Taylor Mill, told the House. Smoking inside schools is already banned.

The bill had lingered on the House calendar for more than a month after unanimously passing the health committee, which Moser chairs. She and Republican leaders indicated that it was short of being supported by a majority of the 61 Republican members, some of whom said it was overreach by the state into a local issue.

The bill got those votes with the help of two floor amendments by Moser. One filed last week would give schools three years to opt out of the ban. An earlier one would allow adults to smoke on field trips or at events off school property events when students are not present.

Opponents of the bill said there are already laws in effect that allow local school boards to decide whether they want to ban tobacco or not, and 42 percent of them had decided to do so.

Moser replied that nearly 60 percent haven't, and noted that 90 percent of adults report that they started using tobacco products when they were teens – and that for the first time in years there has been an uptick in tobacco use, largely driven by e-cigarettes, which can be highly addictive.

"It's just time to stop addiction where it starts and we know that it starts in teen years," she said, adding later, "This would send a strong message that we care about Kentucky youth's health."

Rep. Richard Heath, R-Mayfield, who had been a key opponent of the bill, said he was able to support it with the amendments.

"If the 60 percent of schools that have not adopted a tobacco policy would have done so, we wouldn't be having this discussion today," he said. "It forces the 60 percent who have not taken this stand to come to the table and consciously say we are going to have to do something – we're either going to have to go with it or opt out, and while we're at it, we need to adopt a policy for our schools."

Some members of the Coalition for a Smoke-free Tomorrow, a coalition of 208 organizations, did not support the amendments.

Ellen Hahn, a University of Kentucky nursing professor and the longtime leader in Kentucky tobacco-prevention efforts, noted that cities, counties and schools aren't allowed to opt out of other public health measures. "Opt-out provisions have long been a tobacco industry tactic to derail meaningful and effective tobacco control policies," she said.

Bonnie Hackbarth, vice-president for external affairs with the Foundation for a Healthy Kentucky, called the vote a "major step forward in protecting our youth" and said the foundation would now be able to target its educational efforts to communities that choose to opt out.

That is, if the bill becomes law. It reached the Senate too late Tuesday to get a first reading. Bills need three readings before passage, and there are only three days left in the session, including March 28, the day set for reconsideration of vetoed bills. The "veto session" has often been used to send bills to the governor, who then can veto them without risk of a legislative override.

Sen. Ralph Alvarado, Gov. Matt Bevin's running mate for lieutenant governor and chair of the Senate Health and Welfare Committee, said he hopes to get the bill before his panel for a quick hearing.

"We have three more days," he said. "It took us this long to get it out of the House the way it is . . . so I don't know that we're going to want to make a lot of changes to it. We want to make it as easy as possible for passage."

Alvarado said he is hopeful because a stricter tobacco-free-schools bill passed the Senate in 2017, and he thinks a majority of the Republican caucus would support it, but he still needs to make sure that Senate Republican leaders do.

Moser, in her second term in the legislature and her first as a committee chair, said that she was thrilled that HB 11 had finally gotten a floor a vote, and that she was still hopeful it would pass out of the Senate since Alvarado is so committed to getting it passed.

"I'm grateful that I had so much support, not only the support here but in the community," she said. "It's been huge, a real team effort. It's been a lot of fun to see all the advocacy and all the support."

A floor amendment filed by House Speaker David Osborne, to raise to 21 from 18 the legal age to buy tobacco and electronic cigarettes, was not called for a vote. It replicated a Senate bill that failed in committee. That bill was pushed by Altria Group, the top cigarette manufacturer, which is buying a 35 percent stake in Juul Labs, maker of the most popular e-cigarette.

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

Thinking About Health column: Seniors have until March 31 to change options for Medicare or Medicare Advantage

By Trudy Lieberman, Rural Health News Service

Solicitations for Medicare Advantage plans once again have been arriving in the mail, promising the best bargain since sliced bread. A case in point is one from Emblem Health, a managed-care company in my area that says it considers me what they call a “candidate” for their “special needs plan.” I don’t qualify for such a plan.

The solicitation was interesting, though, for what it promised. Free transportation to and from doctor, hospital, and lab appointments, but only up to 24 one-way trips a year. It also promised “no referrals.” Did that mean no referrals were necessary to visit specialists? The solicitation didn’t say.

That seemed highly unusual for what I am assuming is a Medicare Advantage HMO. HMOs usually require consumers to obtain referrals to specialists.

But shoving aside the questionable advertising pitches such solicitations are known for, that one reminded me that beneficiaries are now in a special enrollment period until the end of March. The special enrollment period, which began Jan. 1, gives seniors a three-month window during which they can switch some of their Medicare arrangements.

It’s also a good time for those who will soon be turning 65 to begin thinking of their options and learn what the rules are once they make their selections.

Until the end of March, if you have a Medicare Advantage plan, you are allowed to switch to another Medicare Advantage plan. Or you can drop a Medicare Advantage plan, return to traditional Medicare and buy a Part D stand-alone drug benefit, says Tricia Neuman, a senior vice president of the Kaiser Family Foundation and a Medicare expert.

What you cannot do, if you have traditional Medicare along with a stand-alone drug plan, is switch to a new drug benefit that might let you save more money on your prescriptions. You can do that only during the open enrollment period in the fall.

Keep in mind that if you drop a Medicare Advantage policy and switch to traditional Medicare, you might have trouble buying a Medigap policy to fill in holes in Medicare coverage. Only four states have what’s known as guaranteed issue Medigap insurance. In New York, Connecticut, Maine, and Massachusetts, people dropping Advantage plans in favor of traditional coverage can buy a Medigap even if they have preexisting conditions. In other states they may not be able to do that.

When might it be useful to consider other options during this brief window for switching?

If you have an Advantage plan that has a drug benefit built in as part of the coverage but you believe you can do better with another plan’s drug benefit, then you might want to do the math and see if a switch helps the budget.

Too many consumers fail to do their shopping for the drug benefit when, in fact, they can save thousands of dollars in pharmaceutical expenses by choosing one plan over another.

This special enrollment period gives you a second chance to save on drug costs.

But you may want to switch Medicare Advantage plans or choose traditional coverage, for other reasons that are becoming clearer. Research is beginning to surface that shows Medicare beneficiaries with high medical needs may have trouble accessing care in some Medicare Advantage plans.

Medicare defines those with high needs as people who have three or more chronic diseases and a functional limitation in activities of daily living or in performing routine daily tasks.

The Office of the Inspector General in the Department for Health and Human Services reported last fall that those with Medicare Advantage plans sometimes had trouble getting claims paid under those plans, or they reported other problems getting help from the plan.

The inspector general said that because so many seniors now have these plans, even low rates of inappropriately denied payments or services could cause “significant problems” for beneficiaries and their medical providers.

Just last month new research reported in JAMA Internal Medicine found that Medicare beneficiaries with high medical needs and those eligible for both Medicare and Medicaid were much more likely to disenroll from Medicare Advantage plans than other beneficiaries.

Researchers at Brown University and Columbia University found that disenrollment from Advantage plans “may indicate that plans do not meet the preferences of enrollees with significant chronic illness.”

This study and the inspector general’s findings offer a cautionary tale for people who will be new to Medicare in the coming months and for sick beneficiaries in Medicare Advantage plans who may want to reevaluate their options during this special open enrollment and next fall when open enrollment comes around again.

What has been your experience in choosing health insurance for this year? Write me at trudy.lieberman@gmail.com.