Friday, June 24, 2016

California insurance chief opposes Humana-Aetna merger, but state agency with actual authority approves it after commitments

"Shares of Aetna and Humana plunged Thursday afternoon after the insurance commissioner of the country’s most populous state said he opposes the proposed merger of the two health insurance giants," Boris Ladwig reports for Insider Louisville.

California Insurance Commissioner Dave Jones said in a conference call and a news release that the Justice Department should oppose the merger because it would reduce quality and consumer choices while increasing prices. "Shares of Humana dropped 1.6 percent, or more than $3, within two minutes after the announcement," Ladwig reports. "Aetna’s shares fell about 0.5 percent within three minutes. Trading volume also spiked for both companies around the time of Jones’ statement."

Aetna noted that Jones has no official authority over the merger, and the only California agency that does, the Department of Managed Health Care, approved it Monday. The agency said it had negotiated commitments, including almost $50 million in health-related expenditures, as part of the approval.

Thursday, June 23, 2016

Work-oriented requirements in Medicaid plan could hit a snag; feds haven't approved a plan with such requirements yet

By Melissa Patrick
Kentucky Health News

Gov. Matt Bevin's plan for Medicaid might not be approved by the Centers for Medicare and Medicaid Services as readily as he suggested, because CMS hasn't approved any plan that has a work requirement.

Bevin's plan would require participants to have what he calls "skin in the game" through premiums and a higher level of involvement in their health care, but it also includes a work requirement.

"All able-bodied working age adult members will be required to participate in community engagement and employment activities to maintain enrollment," says the state's Medicaid waiver proposal.

“There’s nothing in this that is going to be a surprise to them. There’s nothing that we have not talked to them about,” Bevin said at the news conference. “This has been a good, open dialogue. It’s been in good faith. I’m encouraged by that. This is the kind of thing that makes me confident that they will, in fact, support the waiver that we are requesting.”

But that seems to conflict with background information provided by the U.S. Department of Health and Human Services in response to the announcement. HHS says, "States may not limit access to coverage or benefits by conditioning Medicaid eligibility on work or other activities. This requirement is not new."

Indiana and other states have made similar requests to require Medicaid recipients to be employed or actively seeking work, and have been denied. Most recently, Arkansas, which is in the process of submitting its new waiver with a "work referral" program, had originally asked about a work requirement and were told that it would not be approved.

"As we have discussed previously, some of your proposals are neither allowable under federal Medicaid law nor consistent with the purposes of the program. . . . Consistent with the purposes of the Medicaid program, we cannot approve a work requirement," HHS Secretary Sylvia Burwell wrote Gov. Asa Hutchinson in a letter dated April 5."We can, however, support referrals to programs that can help supplicants increase their connection to the workforce and improve their economic outcomes, goals that we support."

Arkansas's new demonstration waiver application says a "work referral" to job training and job search programs will be provided "outside the demonstration" to every Arkansan with no income. In addition, the state will provide information about "work training opportunities, outreach and education about work and work training opportunities through the Department of Workforce Services" to all of the eligible state program beneficiaries. The proposal says this program should help individuals move from the state insurance program to an employee sponsored insurance or private plan.

"You just simply cannot have work requirements in the Medicaid program. It is a safety net program," said Emily Beauregard, executive director of Kentucky Voices for Health, a coalition of groups that favor federal health reform and the state's embrace of it. "I don't expect HHS to accept this waiver as it is written now."

Jessica Ditto, Bevin's spokeswoman, stood firm on the administration's stance that HHS can legally approve Kentucky's plan under Section 1115 of the Social Security Act.

"1115 demonstration waivers give broad authority to HHS to make changes to the standard Medicaid program," Ditto said in an email. "No other state has requested what we are requesting, which is a phased in pilot that is not merely a ‘work requirement’, but rather a community-engagement requirement that can be easily satisfied with several activities, including work, volunteer, job training and education."

The HHS background statement also called into question the monthly premiums that Bevin's plan would require: "States may not impose premiums or cost sharing at levels that prevent low-income individuals from accessing coverage and care."

A threat or a promise?

Bevin, who initially opposed then-Gov. Steve Beshear's expansion of eligibility for Medicaid, boldly said that its continuation depends on whether CMS approves this new plan, saying "If they do not approve this, there will not be expanded Medicaid in the state of Kentucky."

"In fact, that decision is his decision," said Rich Seckel, executive director of the Kentucky Equal Justice Center. "States get to decide whether they have Medicaid expansion or not. The scariness of the threat should not be a factor in evaluating the waiver."

Under federal health reform, Beshear expanded Medicaid to those with incomes up to 138 percent of the federal poverty line, adding more than 400,000 Kentuckians to its rolls. If Bevin holds firm to his statement and the proposal isn't approved, that many Kentuckians would lose their health coverage.

HHS says it will evaluate the waiver based on the law, and suggests that it might take some time to come to an agreement.

“We are hopeful that Kentucky will ultimately choose to build on its historic improvements in health coverage and health care, rather than go backwards," Ben Wakana, national press secretary at the U.S. Department of Health and Human Services, said in a prepared statement. "As in other states, we are prepared to continue our dialogue for as long as it takes to find a solution that continues progress for the people of Kentucky.”

Mark Birdwhistell, a University of Kentucky health-care vice president who is Bevin's special adviser for Medicaid, said the administration hopes to finalize and submit its proposal to CMS around Aug. 1 and get approval by Sept. 30. HHS said that other state's waivers have taken up to seven months of negotiations after submission to CMS to be finalized.

That long a wait would push the decision well past the November election, in which Republicans are trying to take control of the state House, which would give them full control of the General Assembly as well as the governorship. Abolition of the Medicaid expansion before the election could hurt their chances.

The proposal opens a 30-day comment period, in which the state will hold three public hearings: in Bowling Green June 28, Frankfort June 29 and Hazard July 6.

Wednesday, June 22, 2016

Reaction to Medicaid plan is predictably mixed; critics predict federal officials won't approve work-oriented requirements

By Melissa Patrick and Al Cross
Kentucky Health News

Reactions to Gov. Matt Bevin's plan to change Medicaid were predictably mixed, from health-reform advocates saying it is "paternalistic," too complex, removes benefits and adds costs that will create barriers to care, while leading Republicans and the Kentucky Hospital Association sang its praises.

Critics predicted that the Obama administration will reject the plan's requirements that Medicaid recipients have a job, look for one, take job training or do volunteer work.

"You just simply cannot have work requirements in the Medicaid program. It is a safety-net program," said Emily Beauregard, executive director of Kentucky Voices for Health, a coalition of groups that favor federal health reform and the embrace of it.

Judith Solomon, health-policy vice president at the liberal-leaning Center for Budget and Policy Priorities in Washington, D.C., noted that Health and Human Services Secretary Sylvia Burwell told Arkansas this year, “We cannot approve a work requirement.”

Joe Sonka of Insider Louisville wrote that an unnamed HHS official told him "the agency has been clear that states may not limit access to coverage or benefits by conditioning Medicaid eligibility on work or other activities."

The plan has several elements modeled after private insurance, and Mark Birdwhistell, Bevin's special adviser for Medicaid, said it is "commercial insurance on training wheels." That didn't set well with some critics.

"Training wheels are for kids. Right there, that struck me as an inappropriate analysis,"said Rich Seckel, executive director of the Kentucky Equal Justice Center.

"I have heard words like condescending, patronizing. Even if one doesn't use those kinds of adjectives, I do think there is perhaps an inappropriate model of envisioning people as welfare dependents when that's not really who they are and it's a little unfair to them to act on a stereotype," Seckel said. "A theory of welfare dependency kind of pervades this, and yet we know that more than more than half of the people who qualify and got covered were working people."

Seckel and others said the plan, which would seek a waiver of various federal rules, is too complex.

"People on Medicaid have a lot of responsibilities. They have a lot of things they are dealing with on a daily basis," Beauregard said. It is going to be more difficult to navigate, more difficult to keep up with all of the requirements. And it really is just going to place additional burdens on low-income working Kentuckians and their families."

She added, "Navigating the healthcare system is difficult for anyone, but certainly for people who may not be familiar with commercial insurance. I don't think that our goal should be for that people know how to use commercial insurance. I think our goal should be that people use their coverage to improve their health."

The plan removes dental care from the basic Medicaid program but allows members to qualify for it by engaging in a range of activities that could help them improve their health.

"That is the heartbreaker as far as the benefits that are in jeopardy," Seckel said. "We know how closely related that is to the rest of physical health. We know that people have seized upon that opportunity and used that benefit by the thousands. It is something that does affect your confidence in looking for jobs and acting in the workplace and maybe your hire-ability, and yet we've moved that further away and given you a bunch of things that you have to do to get it back."

KVH Chair Sheila Schuster said, "We're talking about a Medicaid expansion population that has been without coverage for years and years and years and just got it for two years, and now you are saying, 'No, you don't get to have oral health,' which is huge. We have one of the worst toothlessness problems in the country and it is very correlated with physical health."

The sharpest criticism came from Democrat Steve Beshear, who as governor expanded eligibility for Medicaid under health reform, adding more than 400,000 people to the rolls.

In a statement issued under the name of Save Kentucky Healthcare, a group he formed, Beshear said Bevin had "declared war on Kentucky’s working families" and "threatened to kick hundreds of thousands of working Kentuckians off of health care. Gov. Bevin seems woefully unaware of what Kentuckians on expanded Medicaid -- and that's construction workers, substitute teachers, nurses’ aides, farmers, our neighbors, friends and family -- do every day to support their families while still being able to take their children to the doctor."

Perhaps anticipating such criticism, Bevin's office had ready a string of quotes praising the plan.

“The Kentucky Hospital Association applauds Governor Bevin for his leadership in presenting a comprehensive plan to transform Kentucky's Medicaid program to achieve better health outcomes for Kentuckians, while also focusing on its financial sustainability," President and CEO Michael Rust was quoted as saying. “We look forward to working with the Bevin administration in helping to implement this innovative plan.”

Bevin's office also quoted several leading Republicans, including state Senate President Robert Stivers of Manchester, whose district has a large Medicaid population: "I am glad to see Governor Bevin and his administration putting an emphasis on personal responsibility with regard to Medicaid expansion. These are some ideas we have been talking about in the Senate for several years. I agree that the idea of making individuals have some 'skin in the game' will make for a more sustainable and better health-care system for Kentucky."

The Foundation for a Healthy Kentucky issued a statement from President and CEO Susan Zepeda, which said in part: "There are areas to applaud in the proposal, including aligning Managed Care Organization practices for greater efficiency, incentives for evidence-based healthy behaviors such as quitting smoking and obtaining a health risk assessment, expansion of presumptive eligibility sites (including local health departments), and commitment to drug use disorder and mental health services."

"The proposal also raises concerns, including the exclusion of dental and vision benefits in the standard benefits package, anticipated significant drops in Medicaid enrollment, elimination of retroactive eligibility and re-enrollment requirements and penalties for those who fail to pay mandated premiums."

Bevin offers 'transformative' Medicaid program with premiums, incentives, work-oriented requirements; expansion at stake

"It's not about the money for the premiums, it's about the learning
experience." --Mark Birdwhistell, Medicaid adviser to Gov. Bevin

(Lexington Herald-Leader photo by Charles Bertram)
By Al Cross and Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Most Kentucky Medicaid recipients would have to pay premiums of $1 to $15 a month, and be more actively involved in their health care, under Republican Gov. Matt Bevin's proposal to maintain his Democratic predecessor's expansion of the program.

If federal officials approve, the program would no longer include some benefits, such as dental and vision care. However, recipients could gain access to those benefits, as well as non-prescription drugs and gym-membership subsidies, by enrolling in job training, volunteer work or health-related classes.

The changes would apply only to able-bodied adults, not pregnant women, the disabled or those deemed "medically frail." Working-age adult members without dependents would be required to participate in volunteer work, have a job, look for one or take job training, on a gradually increasing scale, phased in by county.

At a 50-minute press conference in the Capitol rotunda, Bevin said the program would be "transformative."

"There is nothing good or healthy or productive, long-term for the individual or for society as a whole, that comes from able-bodied, working-age men and women with no expectation of their involvement and no opportunity for that involvement," he said. "So we are providing an expectation and an opportunity and a reward. . . . When they get out there and they get engaged and they start to realize the value that they add, it will change people's lives."

The proposal also asks for Medicaid funding of inpatient substance-abuse treatment, something Bevin said no other state has done, in an effort to address the state's growing drug-abuse problems. This would be a demonstration project limited to 10 to 20 "high risk" counties that have not been chosen.

Bevin's proposal says it "represents the terms under which the Commonwealth will continue Medicaid expansion," and he said that if federal officials don't approve it, he would end the expansion, which provides largely free health care for about 400,000 Kentuckians.

But he said he was confident that federal officials would approve the request, which seeks a waiver of a wide range of Medicaid rules, because he and his aides have been in frequent contact with the Center for Medicare and Medicaid Services and its overseer, Health and Human Services Secretary Sylvia Burwell.

He said nothing in the proposal should be a surprise. “There’s nothing we’re asking them to do that has not been done or is not a stated goal of theirs in other programs,” he said. However, in granting some waivers, CMS has said it would not approve them in other states.

Bevin said during his campaign last year that the expansion was unsustainable, but his plan estimates a modest savings of $300 million to Kentucky taxpayers over the next five years, most of that apparently from tightening up on the managed-care organizations that deal directly with Medicaid members.

"This has been the most lucrative state in America for MCOs to operate," with profit margins four to five times the national average, Bevin said. A recent report said MCOs in Kentucky turned an aggregate profit of 11.3 percent, much higher than any of the 38 other states with managed care.

The federal government is paying all bills for Medicaid expansion enrollees through this year. Next year the state would pay 5 percent, rising in annual steps to the federal health-reform law's limit of 10 percent in 2020. The estimated cost of the state share in the two-year budget that begins July 1 is $257 million.

Bevin said saving money in near-term budgets is not as important as the long-term savings and quality-of-life improvements that can come from improving the health status of one of America's least healthy states.

"It's important to make sure that we have something that, above all else, creates better health outcomes," he said, citing some of Kentucky's poor health statistics. "Number two, we want to familiarize participants with the commercial insurance program" and be more engaged in their communities.

Proposed premiums for first two years. Those above FPL
would pay $22.50 in Year 3, $30 in Year 4, $37.50 afterward.
The premiums would be based on income levels, designed to be less than 2 percent of income, and could be paid by third parties. For non-payment, members above the federal poverty line would be dropped for six months but could re-enter earlier by bringing their payments up to date and taking a financial or health literacy course. Those below the poverty line would incur lesser penalties.

Bevin's proposal would eliminate $3 co-payments for doctor visits and other routine services. Advocates for the poor had said they liked premiums better, because they can be budgeted.

Bevin acknowledged that it would probably cost more to collect the premiums than they would generate, but he said "The savings come from having people who are healthier, who are more engaged. . . . It's not about trying to save money. The money will come from doing the right thing. Better, healthier outcomes result in cost savings on health expenditures."

Medicaid would have a $1,000 deductible, but it would be paid from a state-funded account. At the end of each year, half of the unused amount would be transferred into the recipient's "My Rewards" account. That account would be built by enrollment in classes, job training or volunteer work and could be used to buy additional benefits.

"The deductible account and the My Rewards account empower individuals to be active consumers of health care and make cost-conscious decisions, while simultaneously providing incentives for members to improve their health and be active members of the community," the proposal says.

If Medicaid members are employed and their employer offers health insurance, they and their children would be required to go on it after one year. The state would continue to cover services that are covered by Medicaid but not by an employer's plan.

The plan also calls for a specific enrollment period for Medicaid, which now accepts enrollees year-round. It says making Medicaid more like private insurance will help the many people whose incomes fluctuate, making them eligible for Medicaid one year and federally subsidized health insurance the next.

The proposal opens a 30-day comment period, in which the state will hold three public hearings: in Bowling Green June 28, Frankfort June 29 and Hazard July 6. The administration hopes to finalize and submit its proposal to CMS around Aug. 1 and get approval by Sept. 30, said Mark Birdwhistell, a University of Kentucky health-care vice president who is Bevin's special adviser for Medicaid.

Rogers, other Republicans agree on $1.1 billion to fight Zika, but Democrats don't like where the money would come from

U.S. Rep. Hal Rogers of Somerset and other Republican leaders in Congress "are closing in on a $1.1 billion funding deal to combat the Zika virus, but Democratic leaders are threatening to oppose it over cuts to crucial health-care programs," Sarah Ferris reports for The Hill.

Rogers, the chair of the House Appropriations Committee, and his Senate counterpart, Mississippi Republican Thad Cochran, are trying to meet GOP leaders' goal to approve a Zika funding bill by the July 4 holiday recess. They "expect to finalize a deal on the long-awaited funding package sometime Wednesday evening, according to their offices," Ferris writes.

A Democratic aide told Ferris that the deal would use the Senate’s figure of $1.1 billion, more than double what the House approved, but "would use many of the controversial offsets used in the House Republicans’ bill, such as money for the Ebola virus response and programs under Obamacare. It would also include politically thorny restrictions targeting funding for women's health programs." President Obama has asked for $1.9 billion.

Senate Democrats threatened to block the bill, saying "they’ve been frozen out of the talks," Ferris reports. “There is no bipartisan 'deal' on Zika. The only 'deal' is House and Senate Republicans agreeing to launch more attacks on women's health,” Adam Jentleson, a spokesman for Senate Minority Leader Harry Reid, tweeted Wednesday. Jentleson also called the GOP proposal “deeply unserious.”

Tuesday, June 21, 2016

Kids Count report finds Ky. remains in the bottom 1/3 of states for children's well-being; is this a predictor of the state's future?

By Melissa Patrick
Kentucky Health News

If Kentucky's future lies in the well-being of its children, there's reason to worry, because a recent report shows that Kentucky consistently remains in the bottom one-third of states for this measure.

The 2016 Kids Count report ranks Kentucky 35th in the overall well-being of its children, down from 34th last year. The state showed a significant improvement in its health ranking and a further drop in its teen birth rate, but otherwise didn't show much change from last year's report by the Annie E. Casey Foundation and Kentucky Youth Advocates.

"The real issue is not a drop or increase of one position, but rather that Kentucky continues to be in the bottom one-third of all states," KYA Executive Director Terry Brooks said in a news release. "Are we really content with the idea that two-thirds of America's children are better off than Kentucky kids?"

The annual report offers a state-by-state assessment that measures 16 indicators to determine the overall well-being of children. The latest data are for 2014, and is compared with data from the last six or so years earlier. The report focuses on four major domains: economic security, education, health and family and community security.

Kentucky continues to rank highest in health, climbing to 16th from 24th in 2015, 28th in 2014 and 31st in 2013. Contributors included a continued drop in the number of children without health insurance (4 percent); a 15 percent decrease in child and teen mortality, fewer teens abusing alcohol or drugs (4 percent) and improvements in the percentage of low-birthweight babies (8.8 percent).

The state's greatest drop among the rankings was in economic security, going down to 37th from 32nd last year. Education (27th) saw a slight improvement from the past two years and the family and community (38th) rankings remained similar to the past three years.

The release notes that the state now ranks 10th for the percentage of children with health insurance.

"We are seeing better outcomes for kids in Kentucky, and expanded health coverage and access to quality care play a vital role in making that happen," Susan Zepeda, CEO of the Foundation for a Healthy Kentucky, said in the release. "Research shows that when parents have health coverage, their children are more likely to also be signed up for health insurance."

Another bright spot in the report is that the state's teen birth rate continues to drop. It declined 34 percent from 2008 to 2014. While Kentucky still has one of the nation's highest teen birth rates, it dropped to 35 births per 1,000 girls aged 15-19 in 2014, down from 39 per 1,000 in 2013 and 53 per 1,000 in 2008. The national average is 24 per 1,000, an all-time low.

Kentucky consistently ranks lowest in the "family and community" domain, with 35 percent of its children living in single-parent families; 12 percent living in families where the household head lacks a high school degree; and 16 percent living in high-poverty areas, which are neighborhoods where more than 30 percent of residents live in poverty.

"Kentucky will thrive when policies that support the whole family, caregiver and child, are implemented," Adrienne Bush, executive director of Hazard Perry County Community Ministries, said in the release.

And though the state's education ranking improved to 27th from 30th, not much has changed in these indicators since the foundation started doing this report. The bottom line is that more than half of fourth graders (60 percent) still can't read at a national proficiency level and that the majority of eighth graders (72 percent) still aren't proficient in math. (In 2007, these indicators were 67 percent and 73 percent respectively.)

"Student performance should alarm parents and business leaders and jolt Kentucky leaders into making fundamental education reform a policy priority to ensure college and career readiness," Brooks said.

In addition, more than half the state's three-and four-year-olds (58 percent) don't attend pre-school and 17 percent of its high school students don't graduate on time.

Perhaps the direst message from the report is about the state's economic well-being. One in four Kentucky children live in poverty (26 percent), a rate that has remained higher than it was pre-recession when it was 23 percent, says the release. Nationally, the child poverty rate is 22 percent.

"Growing up in poverty is one of the greatest threats to healthy child development," says the report. "Poverty can impede cognitive development and a child's ability to learn."

The report also says 35 percent of Kentucky's children live in homes with parents who don't have secure employment, which places the state in the bottom 10 states for this indicator. It also found that 28 percent live in households with a high housing-cost burden.

The release suggested "bipartisan solutions" to improve the well-being of Kentucky's children, including expanding oral health coverage; supporting school-based health centers; education reform that includes public charter schools, expanded child care assistance and family-focused tax reforms.

Sunday, June 19, 2016

Dangers of HIV and hepatitis from intravenous drug use reach far beyond addicts and families, threatening a wide swath of Ky.

The growing use of heroin and the abuse of prescription painkillers in Kentucky also mean that the state "is being ravaged by the diseases that follow in their wake: hepatitis and HIV. These dangers also reach far beyond addicts and their families, threatening a wide swath of the population," Laura Ungar reports for The Courier-Journal.

Kentucky has one-fourth of the 220 U.S. counties that the U.S. Centers for Disease Control and Prevention had judged to be at high risk for outbreaks of HIV and hepatitis C among intravenous drug users, Ungar notes in the second installment of a three-part series on heroin in Kentucky and adjoining states.
"Acute hepatitis B rose 114 percent in Kentucky, Tennessee and West Virginia from 2009 to 2013, even as incidence remained stable nationally, according to one study," she reports. "According to another study, the rate of new hepatitis C cases among people 30 and younger more than tripled from 2006 to 2012 in Kentucky, Tennessee, Virginia and West Virginia. More recently, cases of acute hepatitis B and C in Kentucky reached 281 last year, up from 120 in 2003."

Dr. Nora Volkow, director of the National Institute on Drug Abuse, told Ungar that hepatitis C has become the top cause of death from reportable infectious diseases in the U.S., and an HIV outbreak in Austin and Scott County, Indiana, “was a wake-up call” for the country. Ungar notes, "Addicts may also be spreading both diseases without knowing it. Up to three in four people with hepatitis C, and one in eight with HIV, don’t know they have it, experts say."

Dr. William Cooke, an Austin physician "who treats dozens of patients with HIV and hepatitis, said many communities are ill-equipped to handle the threat," Ungar writes. "All over the region and nation, he said, there’s too little substance abuse treatment, too little emphasis on the poverty that often accompanies addiction and too little compassion."

Kentucky has authorized needle exchanges where addicts can get clean syringes to avoid the threat of infection from contaminated needles. "Officials say needle exchanges are an important part of a comprehensive strategy to control disease," Ungar notes. "But critics argue these programs enable drug use, and many area residents reject the idea of using public money to fund them. So the prospect of more syringe exchanges in the region remains uncertain."

Ungar gives the basics of how the diseases spread: "HIV, which can be transmitted through semen and other bodily fluids in addition to blood, is mainly spread by having unprotected vaginal or anal sex with someone who has HIV, or sharing used needles, which can harbor live viruses for up to 42 days. But it also can be transmitted to health care workers by needle sticks, or from mother to child during pregnancy, birth or breastfeeding, especially if the mom isn't taking medicine.

"Hepatitis B and C, which are caused by separate viruses, are easier to catch than HIV because there are higher levels of virus in the blood. Hepatitis B is more often contracted through sex or accidental needle sticks than hepatitis C, but both types are commonly spread by sharing tainted needles."

AMA, led by Ky. doctor, says gun violence is public-health crisis; calls for research, background checks, waiting periods for all guns

The American Medical Association, led by a Kentucky emergency-room physician, declared gun violence a public-health crisis last week and endorsed waiting periods an background checks for purchases of all firearms, not just handguns.

"The AMA, the country's largest doctor group, also vowed to lobby Congress to overturn a decades-old ban on gun violence research by the Centers for Disease Control and Prevention," two days after the Orlando shooting that left 49 dead and 53 wounded, reports Kimberly Leonard of U.S. News and World Report. "The AMA joins the American College of Physicians in its position, which has been calling gun violence an epidemic since 1995."

Dr. Steven Stack
AMA President Steven Stack of Lexington said the research "is vital so physicians and other health providers, law enforcement and society at large may be able to prevent injury, death and other harms to society resulting from firearms. . . . With approximately 30,000 men, women and children dying each year at the barrel of a gun in elementary schools, movie theaters, workplaces, houses of worship and on live television, the United States faces a public-health crisis of gun violence."

Leonard notes, "Federal law doesn't technically outlaw the CDC from studying gun violence, but prohibits the agency from using federal dollars to advocate or promote gun control. Though President Barack Obama lifted the research ban through executive order nearly three years ago, Congress has blocked funding for these studies."

The National Rifle Association has called the public-health approach a back-door path to more gun control, Leonard writes, and "has said that doctors shouldn't be asking patients about gun ownership because they are not gun safety experts."

"Who will Congress listen to now: the healers or the merchants of death?" Lexington Herald-Leader columnist Tom Eblen asked to start his Sunday column. "The AMA's stand is unlikely to change anyone’s mind about gun control. But it underscores the absurdity of Congress’ two-decade effort to block legitimate scientific research that could reduce gun deaths and injury."

Suicides accounted for about two-thirds of the 33,390 firearms deaths in the U.S. in 2014. The CDC "said 627 people were killed in Kentucky that year with firearms, a rate of 13.8 per 100,000 population, higher than the national average of 10.2," Eblen reports. He said research on gun violence could reduce those figures, just as research into auto accidents has reduced such fatalities.

Read more here:
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Saturday, June 18, 2016

Panel considers involuntary, court-ordered outpatient treatment for mentally ill; foe says would infringe on personal rights

By Melissa Patrick
Kentucky Health News

Representatives from five groups involved in mental health offered legislators solutions June 15 for ending the revolving door between hospitalization, incarceration and homelessness that often exist for those with severe mental-health conditions.

Many who spoke at the three-hour meeting of the  Interim Joint Committee on Health and Welfare said judges should be able to order mentally ill adults who meet strict criteria into an "assisted outpatient treatment" program. Others said that would add costs and a burden to the judicial system, and infringe on personal liberties. But all agreed that the state lacks resources to care for such adults.

Shelia Schuster, executive director of the Kentucky Mental Health Coalition, voiced strong support for the idea. She said its main goal would be to create a narrowly defined program "to access supported outpatient treatment under a court order, again without having to be involuntarily committed or coming through criminal justice system."

Now, a mentally ill person who needs care but does not want it can only be court-ordered into treatment after being released from a hospital or jail.

Various versions of this legislation have have been filed in the General Assembly since 2013. Last year's version, House Bill 94, passed out of the Democrat-led House, but died in the Republican-led Senate. The bills are often referred to as "Tim's Law," named for Tim Morton, a schizophrenic who was hospitalized involuntarily 37 times by his mother because this was the only way she could get him the treatment he needed. Morton died in 2014.

“We do want to make sure that those individuals, like Tim Morton, who are very ill and who are unable to recognize it, who spend much of their lives in the revolving door of hospitalization, homelessness, or incarceration, are afforded a new opportunity to stay in treatment long enough to see the positive effects and the road to recovery,” Schuster said.

Steve Shannon, executive director for the Kentucky Association of Regional Programs, said the state needs assisted outpatient treatment to keep those with mental-health conditions out of the criminal justice system.

"If we can keep a person out of criminal justice involvement, it is better for them, " he said. "Folks have enough challenges already; why add that piece to it? . . . It affects housing, it affect employment."

Shannon also proposed that the state seek a Medicaid waiver to help pay for housing and supported employment for such adults, and a spend-down option to allow the poor on Medicare to also get Medicaid, which offers more services.

Jeff Edwards, division director of Kentucky Protection and Advocacy, who supports does not support Tim's Law said "assertive community treatment" teams are already available to this population, but only on a voluntary basis. He also noted that the ACT program is laden with issues, including geographical access, wait times to get services, and frequent staff turnover.

"Right now, you have to live in one of 56 counties to get the ACT services," he said. "We have to expect quality services, no matter where a person lives in the state."

Ed Monohan of the Department of Public Advocacy, a long-time opponent of the court-ordered treatment model, said  he supports enhancing the ACT teams, which provide a comprehensive array of community supports to this population through individual case managers who are available 24 hours a day.

"Long-term, engagement with clients, with people, is a far superior long-term strategy than coercion through a court system," Monohon said. "The mental-health system, rather than the court system, is the better place to really address this long-term. ... Their liberty is at stake with this coercion."

"I know it is about civil liberties and the rights of individuals, but for them, in the disease process, they have lost the ability sometimes to make those decisions clearly for themselves," said Rep. Addia Wuchner, R-Florence, after sharing deeply personal stories about a family member who had severe mental illness.

During an impassioned plea of support for Tim's Law, Kelly Gunning, director of Advocacy National Alliance on Mental Illness in Lexington, told the story of how her son, while under the care of an ACT team, "brutally assaulted" both her and her husband in January. She emphasized that while the ACT program does offer a "robust array of services," it is based on voluntary compliance.

"They are voluntary. Do you hear me? They are voluntary! If my son doesn't want to open the door for his ACT team, or his doctor who comes to his home, he doesn't have to," she said. "And (as) we were cleaning out his home, we found a years stockpile of medication untouched, untaken because he doesn't believe he has an illness."

Allen Brenzel, clinical director with the state Department for Behavioral Health, Development and Intellectual Disabilities, along with many others at the meeting, acknowledged that a lack of resources is a large part of the problem.

"I mostly hear unity around the issue that we must do better," he said, adding that not only assisted outpatient treatment is needed: "It's going to be the allocation of resources and the moving of resources to appropriate places."

Committee Co-Chair Sen. Julie Raque-Adams, R-Louisville, encouraged the group to examine this issue "holistically" and committed to working on a solution. "Across the board, this is one of those issues that we can no longer stick our heads in the sand and ignore,"' she said.

Friday, June 17, 2016

Donna Arnett, new UK public-health dean, says research is important to reducing Kentucky's huge health disparities

Donna Arnett, dean of the College of Public Health at the University of Kentucky, says research is essential to reducing Kentucky's huge health disparities, as illustrated by the recent release of data showing a wide range in life expectancy among counties.

In a UK news release and video, Arnett, a genetic epidemiologist and native of London, noted the "devastating impact" that obesity, diabetes, cancer, drug-abuse and overdose deaths have in her native state.

“Public health is at the heart of answering the challenges of those critical diseases in Kentucky, " Arnett said. "We in public health are really at the forefront of first detecting these epidemics, and then finding strategies and interventions to help eliminate those disparities.”

Arnett's passion for research began during her early career as a nurse when she was working next to a dialysis clinic at a Department for Veterans Affairs hospital and noticed that more African-American men were sent to the clinic than men of other races.

“I’ll never forget, in my hallway in this VA hospital, every day men would be coming down the hallway, and they’re almost all African American,” Arnett said. “I said, ‘You know, there has to be something about being African American and having kidney failure.’”

This prompted her to create an informal hypothesis that this was linked to a genetic code in African American men that put them at a higher risk of kidney failure. She was right. While her original hypothesis evolved, it was validated after numerous studies.

Arnett obtained a doctorate in epidemiology from the University of North Carolina and built a career in public health. She has received research funding from the National Institutes of Health for more than 20 years, and brought three active NIH projects to UK when she became dean of the public-health college in 2015. Among other leadership roles, she has served as the president of the American Heart Association.

Serving as AHA president showed Arnett that "solving the most urgent health problems in the nation requires the collaboration among different professionals and organizations devoted to health and uniting the research efforts and knowledge of diverse investigators," and she is working to establish partnerships across the state, the UK release and video say.

"Science now is really multi-disciplinary," Arnett said, "so we have to function in a team."

Thursday, June 16, 2016

Painkillers appear to increase risk of deaths other than overdoses, according to new study of Medicaid patients in Tennessee

"Accidental overdoses aren't the only deadly risk from using powerful prescription painkillers," The Associated Press reports. "The drugs may also contribute to heart-related deaths and other fatalities, new research suggests."

A study of of more than 45,000 Medicaid patients in Tennessee from 1999 to 2012 found that "those using opioid painkillers had a 64 percent higher risk of dying within six months of starting treatment compared to patients taking other prescription pain medicine," AP reports. "Unintentional overdoses accounted for about 18 percent of the deaths among opioid users, versus 8 percent of the other patients."

"As bad as people think the problem of opioid use is, it's probably worse," said Vanderbilt University professor Wayne Ray, the lead author of the study report. "They should be a last resort and particular care should be exercised for patients who are at cardiovascular risk."

The report in the Journal of the American Medical Association noted that opioids can slow breathing and worsen the disrupted breathing associated with sleep apnea, which could lead to irregular heartbeats, heart attacks or sudden death.

The patients in the study "were prescribed drugs for chronic pain not caused by cancer but from other ailments including persistent backaches and arthritis," AP reports. "Half received long-acting opioids including controlled-release oxycodone, methadone and fentanyl skin patches. . . . There were 185 deaths among opioid users, versus 87 among other patients. The researchers calculated that for every 145 patients on an opioid drug, there was one excess death versus deaths among those on other painkillers. The two groups were similar in age, medical conditions, risks for heart problems and other characteristics that could have contributed to the outcomes."

Wednesday, June 15, 2016

Court of Appeals orders Lexington abortion clinic closed for now

By Al Cross
Kentucky Health News

Reversing a lower court's ruling Wednesday, the Kentucky Court of Appeals said Lexington's only location for legal abortions must stop performing them pending a lawsuit by the state that seeks to require it to be licensed as an abortion facility.

Fayette Circuit Judge Ernesto Scorsone declined in March to issue an injunction to close EMW Women’s Clinic on Burt Road, saying that the state failed to show that it was likely to win its lawsuit and that allowing it to stay open in the meantime would cause any irreparable injury. He found that the clinic was operating legally, and closing it would be “against the public interest” because it is the only clinic that routinely provides abortion services in the eastern half of the state and the right to an abortion is constitutionally protected.

But the facility is licensed as a physician's office, not as an abortion clinic, and a three-judge panel of the Court of Appeals, all of them women, unanimously agreed with the administration of Gov. Matt Bevin that it needs the latter license to operate legally. The judges said Scorsone had misinterpreted the licensing requirements and didn't give proper weight to the evidence, which was that all the clinic does is perform abortions and related procedures.

The clinic's owner, Dr. Ernest Marshall of Louisville, testified that the Lexington business "originated as a doctor's office" but has narrowed its line of work in recent years, especially after his partner died in December 2013. He said it was a simple facility compared to his EMW Women's Surgical Center in Louisville, which is licensed as an abortion facility and performed 2,773 abortions last year compared to 411 at the Lexington facility, which does abortions only in the first 12 weeks of pregnancy.

Scorsone said Marshall "has a strong argument" that he didn't need an abortion license because the Cabinet for Health and Family Services reached that conclusion after its last previous inspection in 2006 and the clinic doesn't have $1.5 million worth of equipment, at which point an abortion-clinic license is required. But the appeals court pointed out that state law says an abortion facility is "any place in which an abortion is performed" and "We see no reason why an exemption determination should be determinative a decade later," after the nature of the facility had changed.

The appeals court said Scorsone also erred in saying denial of an injunction wouldn't cause irreparable injury, because the cabinet and the citizens would be harmed "if the cabinet is not allowed to correct the alleged violations of its licensing requirements." It said that is a legal presumption that Marshall could have rebutted but did not. It also cited the cabinet's latest inspection, which found "expired medications, defective equipment, [a] torn examination table and dust accumulation."

In granting the injunction prohibiting abortions at the facility, the court said "There is a substantial legal issue as to whether EMW Lexington qualifies as a private physician's office, where it performed only abortions in the last year."

As for the availability of abortions in the eastern half of the state, the three judges said Marshall presented no evidence regarding "the location of the women EMW Lexington serves" and noted that it refers women past the 12th week of pregnancy to its Louisville facility. "As the cabinet points out, this case is not about a woman's right to an abortion," Judge Allison Jones wrote.  "The cabinet is not seeking to prevent women from obtaining abortions [but] to enforce its right to regulate the manner in which abortions are performed in this commonwealth." Judges Sara Combs and Debra Lambert joined in the opinion.