Sunday, October 22, 2017

McConnell says he's waiting to hear from Trump before deciding on bill to restore cost-sharing subsidies for Obamacare policies


Kentucky Health News

Senate Majority Leader Mitch McConnell of Kentucky said Sunday that he's waiting for a clear signal from President Trump before acting on a bipartisan bill to restore cost-sharing subsidies for individual health-insurance policies under Obamacare.

“I'm waiting to hear to hear from President Trump what kind of health-care bill he might sign,” McConnell said on "State of the Union" on CNN. “If there’s a need for some kind of interim step here to stabilize the market, we need a bill the president will actually sign. And I’m not certain yet what the president is looking for here, but I’ll be happy to bring a bill to the floor if I know President Trump would sign it.” He added, “I think he hasn’t made a final decision.”

On Oct. 12, Trump said he would end the subsidies that reduce out-of-pocket costs for lower- and moderate-income people, because Congress had failed to repeal and replace the Patient Protection and Affordable Care Act. A few days later, he said he would support a bill to extend the subsidies for two years and give states more flexibility in Obamacare. But the next day, the president said "I can never support bailing out" insurance companies, which the government reimburses for the discounts.

The subsidies go to people with incomes up to 250 percent of the poverty line, about $30,000 for an individual and $61,000 for a family of four. About half the 80,000 Kentuckians with Obamacare policies get the subsidies.

Trump's press secretary suggested that the president could support the bill if it were changed, giving as an example even more Obamacare flexibility to the states: converting the funding to block grants. "White House officials said later that Trump would only sign an interim bill that also lifts the tax penalties that Obama’s health care law imposes on people who don’t buy coverage and employers who don’t offer plans to employees," reports Jill Colvin of The Associated Press. "The White House also wants provisions making it easier for people to buy low-premium policies with less coverage."

Democrats oppose all those ideas, and Senate Minority Leader Chuck Schumer, D-N.Y., said McConnell should bring the bipartisan bill to the Senate floor because it would pass with the votes of all 48 Democratic senators and at least 12 Republicans. Sixty votes are required in the Senate to overcome filibusters, except on budget-reconciliation bills.

“We have an agreement. We want to stick by it,” Schumer said, referring to the deal between Republican Sen. Lamar Alexander of Tennessee and Democratic Sen. Patty Murray of Washington, the chair and ranking minority member of the Senate health committee.

Replying to McConnell, Schumer said Trump “holds the key” to preventing further cost increases for Obamacare policyholders. He said, “Now that Leader McConnell has made it clear he will put the Murray-Alexander bill on the floor as soon as the president supports it, the president should say that he does.”

Even if the bill was to pass the Senate, it would face stout opposition in the House, where Republicans have greater control and Speaker Paul Ryan says he opposes the measure. However, Democrats will gain leverage near the end of the year, when their votes will be needed in the Senate to pass legislation to fund the government and keep it open. McConnell has said he opposes government shutdowns.

State posts weekly report on spread of flu, by county and region

Flu season has arrived, and it's time to get your shot. But if you are curious about the spread of flu in your region, the state Department for Public Health has started an online weekly report that shows the number of influenza cases in each of Kentucky's 15 area development districts and counties that have reported cases of the flu.

The data come from reports the department compiles and sends to the federal Centers for Disease Control and Prevention. It is based on laboratory-confirmed cases defined by molecular virus testing and positive virus culture test results; rapid-positive tests are not included.

The report is at http://chfs.ky.gov/dph/epi/Influenza.htm and is updated each Friday before noon, the Cabinet for Health and Family Services said in a news release.

"This new public service is an example of the cabinet’s priority to strengthen data collection and analytics and then to make the information more easily accessible," the release says. 

The health department "relies on sites such as doctors’ offices, hospitals and health departments to help track the level of influenza activity in the state and to identify which strains of the flu are circulating in Kentucky," the release explains. "These voluntary sites collect data and report influenza-like illness cases according to age groups each week. This sampling represents only a small percentage of influenza cases for the state, but contributes to the ongoing assessment of flu activity in the commonwealth and helps determine the weekly level of flu activity."

Kentucky’s current flu level is classified as “sporadic,” with 18 confirmed cases. The news release says, "Sporadic activity indicates that small numbers of laboratory-confirmed influenza cases or a single laboratory-confirmed influenza outbreak have been reported, but there is no increase in cases of influenza-like illnesses."

Vaccination can be given any time during the flu season. The recommends flu vaccine for everyone over six months of age. People who are strongly encouraged to receive the flu vaccine because they may be at higher risk for complications or negative consequences include:
• Children age six months through 59 months;
• Women who are or will be pregnant during the influenza season;
• Persons 50 years of age or older;
• Persons with extreme obesity (body-mass index of 40 or greater);
• Persons aged six months and older with chronic health problems;
• Residents of nursing homes and other long-term care facilities;
• Household contacts (including children) and caregivers of children younger than 5, particularly contacts of such children, or of adults 50 and older;
• Household contacts and caregivers or people who live with a person at high-risk for
  complications from the flu; and
• Health care workers, including physicians, nurses, medical emergency-response workers, employees of nursing home and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.

The flu can cause fever, headache, cough, sore throat, runny nose, sneezing and body aches. Flu can be very contagious. For more information on influenza or the availability of flu vaccine, Kentuckians should contact their primary care medical provider or local health department. Influenza information is also available online at https://www.cdc.gov/flu/index.htm. Here's a partial screenshot of the weekly report:

Saturday, October 21, 2017

Study finds more than 1/4 of adults with health insurance are under-insured, largely because their deductibles are so high

By Melissa Patrick
Kentucky Health News

More than one-fourth of U.S. adults with health insurance were under-insured in 2016, including 44 percent who got their coverage from the federal marketplace and almost 25 percent who got their coverage from employer plans, according to a recent study.

Using data from The Commonwealth Fund's 2016 Biennial Health Insurance Survey, a report from the fund found that of all working-age adults who had health insurance for a full year in 2016, 28 percent, or about 41 million people, were underinsured.

This was up from 23 percent in 2014 and 12 percent in 2003, the first year the survey asked questions on the topic.
People in the study were considered underinsured if they had health insurance plans with high deductibles and high out-of-pocket expenses relative to their income.

More than half of the under-insured in the survey said they had trouble paying their medical bills, and 45 percent said they went without needed care because of cost.

“People who are under-insured face problems affording health care at rates similar to those seen for people with no health insurance at all, and they are almost as likely to skip needed care and to end up in debt when they get sick," Sara Collins, lead author of the study, said in a news release.

A 2016 Kentucky Health Issues Poll found that nearly one-third of Kentucky adults, whether they had health insurance or not, struggled to pay their medical bills, and one-fifth said they often delayed or skipped needed medical care because of cost.

The Commonwealth Fund's national report says the added cost burden that comes with high-deductible plans, which have become the norm, has created a steady increase in the rates of under-insured people.

In 2016, the study found that 13 percent of adults enrolled in a private plan had a deductible of $3,000 or more, up from just 1 percent in 2003. It added that only 22 percent of private insurance plans offered plans with no deductibles in 2016, down from 40 percent in 2003.

And the deductibles are even higher in the individual marketplace. "Twenty-three percent of adults with individual and marketplace plans had plan deductibles equaling 5 percent or more of income," says the report.

For example, the least expensive 2017 "silver" plan that popped up on Healthcare.gov for a Kentucky family of four making around $75,000 a year requires a $548 monthly premium (after applying the $441 per month premium tax credit) and a $12,300 deductible. It also required a $30 co-payment for every visit to the primary-care provider, with a $14,000 out-of-pocket family maximum.

The survey also found that about half of the under-insured adults who had problems paying their medical bills or had medical debt said they had used up all their savings to pay their bills, with 40 percent of them saying they now have a lower credit rating because of their bills.

This should come as no surprise. A 2017 GOBankingRates survey found that more than half of Americans (57 percent) said they have less than $1,000 in their savings accounts and 39 percent of them had no savings at all. A separate survey found that 49 percent of all Americans live paycheck-to-paycheck.

The authors say that extending the federal cost-sharing reduction payments to more enrollees, excluding more services from plan deductibles, and increasing the required minimum value of employer plans, along with addressing rising health-care costs, are possible ways to make health insurance more affordable.

Friday, October 20, 2017

Latest effort for a big increase in Kentucky's cigarette tax faces a daunting assignment, based on experience in other states

Kentucky Health News

If the latest effort to raise Kentucky's cigarette tax by $1 a pack begins to gain momentum, it can expect a big pushback from tobacco companies, if past experience in Kentucky and other states is any indication.

"Many states — Missouri, Kentucky and Georgia among them — have not significantly increased their cigarette fees in decades, bowing to pressure from tobacco lobbyists and an ingrained antipathy among conservatives to raising taxes of any kind," William Wan reports for The Washington Post.

"As a result, America’s smokers are increasingly concentrated in states where cigarettes are cheap. A pack of cigarettes will soon cost $13 in New York City, where a tax hike of $2.50 was recently passed. But in Kentucky . . . you can buy that same pack for $4.77, on average."



Kentucky has the nation's second-highest smoking rate and still produces about $250 million worth of tobacco each year, though the number of tobacco farmers in the state has declined to about 4,000. The CEO of the Foundation for a Healthy Kentucky cited the latter figure Oct. 18 in announcing a campaign with many partners to get the state legislature to raise the state's cigarette tax of 60 cents a pack by at least $1 to discourage smoking and raise money for the state.

University of Kentucky Nursing Professor Ellen Hahn, who has led tobacco-control efforts in the state for many years, told the Post, “People around here just don't like the ‘tax’ word. Between that and the grip of the tobacco industry on our legislature, it’s hard to convince anyone, especially politicians.”

The big difference in state cigarette taxes, and thus cigarette prices, "is the result of a long-running war between tobacco companies and health advocates," Wan writes. "It is also, experts say, one of the biggest reasons low-tax states now suffer from high rates of cancer, heart disease, diabetes and a multitude of other tobacco-related diseases."

Wan adds, "The battle has increasingly focused on not just whether states should increase taxes, but also by how much. Health advocates regularly fight for $1 to $2 increases, while cigarette companies push to limit them to hikes of 25 to 50 cents. That has led, at times, to bizarre conflicts. Last year, when Missouri considered raising its cigarette tax for the first time in more than two decades, tobacco companies supported the increase, while health groups such as the American Cancer Society strongly opposed it. The reason? The proposed increase was so low — either a gradual 23-cent hike or a 60-cent increase over four years — that researchers concluded smokers would pay it and keep smoking."

In Montana, a bill to raise the cigarette tax died quickly, and was even abandoned by some of its sponsors, after the two main cigarette makers, Philip Morris and R.J. Reynolds, "swarmed the halls of the state capitol, wined and dined Republican leaders, launched a sophisticated call-in campaign, and coached witnesses for hearings," Wan reports.

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, told Wan, “It’s incredibly frustrating because, unlike so many other problems in the country, this is one case where we know the solution. Not only that. It’s a solution that’s widely popular, doesn’t cost the government anything, yet these states refuse to do it.”

Myers sees little hope for a substantial tax hike in Kentucky. “People have literally been dying from this problem for years, and that still hasn’t made a difference for those legislators,” he told Wan. “The only hope I see is the economics: when the mounting health-care costs from sick and dying smokers finally gets to a point where lawmakers have no choice but to raise the cigarette taxes.”

Cigarette makers say big tax increases are unfairly exorbitant and their industry is overtaxed, Wan reports: "They point out that from 2000 to 2014, federal and state cigarette taxes have been raised 120 times. They argue that higher taxes hit the pocketbooks of convenience store owners and smokers and amount to a regressive tax on the poor. That last argument . . . angers public-health officials, because studies show that such taxes are especially effective at reducing smoking among lower-income people. By helping them quit, advocates say, taxes help struggling families escape the economic burden that cigarette addiction puts on their monthly income.

"But the most effective argument by tobacco companies has been the libertarian one: That adults should be free to choose whether to smoke and not be prodded into quitting by a nanny state."

Thursday, October 19, 2017

Judge lets seven recovery clinics in Eastern and Central Kentucky re-open, but they remain under investigation

A circuit judge has ruled that seven recovery clinics in Eastern and Central Kentucky will be allowed to remain open, Jeff Noble reports for The Times-Voice in Jackson.

The Hazard, Jackson, Paintsville and Richmond clinics were raided on Aug. 29, which Noble reports resulted in five arrests at the Jackson clinic. These clinics remain under investigation by the state attorney general's office. The other three clinics are in London, Mount Sterling and Frankfort.

In issuing the temporary injunction in Breathitt Circuit Court, Judge Frank A. Fletcher wrote, “If the court does not issue a temporary injunction, the plaintiffs (The Recovery Center, LLC and Dr. George Burnette) and their patients and their employees, will suffer irreparable harm."

Noble reports that the seven clinics employ more than 78 workers and 20 contract physicians and treat more than 2,200 patients, almost all of whom receive Medicaid. All of the clinic's Medicaid payments have been withheld since Sept. 19. The judge ordered the payments resumed Oct. 16. 

Wednesday, October 18, 2017

Broad anti-smoking coalition launches with a lofty goal: adding $1 to cigarette tax in next legislative session

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- More than 100 people representing at least 84 groups gathered at the state Capitol Annex Oct. 18 to launch the Coalition for a Smoke-Free Tomorrow, with its leader boldly stating they hope to add $1 to Kentucky's 60-cent-per-pack cigarette tax in the 2018 legislative session.

"We hope that we can make some progress on this cigarette tax in this session that is coming up," Ben Chandler, chair of the coalition and president and CEO of the Foundation for a Healthy Kentucky, said. Noting that the big news of the day was a plan for the state's expensive pension crisis, he said, "We have one of the answers," revenue from the tax.

Coalition supporters displayed signs. (Photos by Melissa Patrick)
The foundation recently adopted smoke-free advocacy as its leading cause and is coordinating the coalition -- to the extent of lending it a modified version of its logo, which advocates held up during the launch.

Ellen Hahn, director of the University of Kentucky's Kentucky Center for Smoke-free Policy and a long-time advocate for a statewide ban on smoking in enclosed public places, said after the meeting that the Foundation is a "bully pulpit" that will speak for all of the advocates, and the coalition represents the federal Centers for Disease Control and Prevention's best practices for tobacco control -- increased taxes to discourage smoking, smoke-free policies, and helping people who want to quit.

"It's nice to have a fresh voice," she said. "I've said for years we need a bully pulpit. We need somebody who will speak up and say we need to do this."

At 24.5 percent, Kentucky has the second highest smoking rate in the nation, barely behind West Virginia's 24.8 percent. The national average is 15.1 percent. Almost 17 percent of Kentucky's high-school students are smokers, more than double the national average of 8 percent. Nearly 9,000 Kentuckians die from cancer or another smoking-related illness each year, and the state spends about $2 billion annually on smoking-related health care.

"Welcome to the cancer capital of the nation," Chandler said, noting that cancer hasn't declined as much in Kentucky as it has nationally, and cancer rates are increasing in parts of the state. He said the high smoking rate is partly to blame.

The coalition has set three goals: the $1 increase in the cigarette tax, with parallel increases in taxes on other tobacco products; helping counties and cities enact comprehensive smoking bans; and educating the public and health-care providers about a new law that requires health insurers to provide barrier-free coverage for all federally approved tobacco-cessation medications and programs.

Ben Chandler, president/CEO, Foundation for a Healthy Ky.
"These are proven laws and policy changes that will reduce our smoking rates, that will reduce our health care costs, that will in fact improve our health," Chandler said. "What's more, these policy changes don't cost an arm and a leg. In fact, they can dramatically improve Kentucky's troubling budget situation."

Chandler said Republican Sen. Stephen Meredith, a retired CEO of Twin Lakes Regional Medical Center in Leitchfield, has told him he plans to pre-file a bill to raise the cigarette tax by $1.

The current 60-cent tax is about a third of the national average of $1.71 per pack. The coalition projects that a hike to $1.60 a pack would bring in $266 million the first year.

Republican Sen. Ralph Alvarado, a Winchester physician who has sponsored several unsuccessful smoke-free bills, including one last session to make schools and school activities smoke-free, says he thinks the timing could be ripe to pass a cigarette tax because the pension system needs more money and Gov. Matt Bevin wants to reform the state's tax system.

Sen. Ralph Alvarado, R-Winchester
"The governor has charged that everything will be on the table when it comes to this tax proposal, so consequently now is the time to start looking at proposals that by themselves maybe would not pass, but as part of a larger reform has a chance to become law," Alvarado said.

Chandler said anything less than a $1 increase wouldn't work because it could be absorbed by the tobacco companies through things like temporary price cuts or other promotional discounting. He also noted that it has to be high enough to make people want to quit. "Otherwise it's just a tax increase with no health benefits, and what we care about are the health benefits,"he said.

Skeptics of a cigarette-tax increase say its revenue would decline as more people stop smoking, but Chandler said "We don't think it'll decline a whole lot," based on other states' experience. "Of course, the more it declines, the better. Any decline that does take place in the revenue the state receives is more than made up in savings on health-care cost. Anyway you look at it, it is a win for the state budget."

David Adkisson, president and CEO of the Kentucky Chamber of Commerce, said 90 percent of the chamber's members support a statewide smoking ban and legislation that would increase the cigarette tax. He added that the the costs of smoking to employers, in extra health care costs and reduced productivity, is almost $6,000 per smoking employee each year.

Jacob Steward of Bourbon County High School won applause.
"Our smoking situation in Kentucky is not only killing us, it's bankrupting us," he said.

Jacob Steward, a sophomore at Bourbon County High School and a member of a group called Students Making a Community Change, said he thought the additional tax would "significantly help" teenagers quit smoking because they would no longer be able to afford them, but he also suggested that it's also important to figure out why they ever started smoking in the first place.

"I think that one thing that should come out of this is maybe better outreach for those students. For people to actually empathize with them and understand why they started smoking to begin with," he said to a room full of applause.

Dr. Patrick Withrow, a cardiologist and director of public outreach for Baptist Health Paducah, held up a huge model of a cigarette and called it one of the most effective drug-delivery devices.

"Raising the price of cigarettes is the single most effective thing we can do to decrease smoking in Kentucky. If we decrease smoking in Kentucky, we decrease smoking disease, we decrease smoking death, and we improve quality of life," he said.

Chandler said the coalition will work systematically to help communities across the state become smoke free, with the long-term goal of passing a statewide smoke-free law. "Ultimately the goal is to get a critical mass of communities," he said. "We have 33 percent of the population covered right now; we'd like to raise that considerably and at that point maybe the state legislature might be ready to pass a statewide law."

The state House passed a smoking ban in 2014, but the bill died in the Senate, and Bevin, who took office in 2015, says smoking bans should be a local issue.

Chandler, who ran for governor as attorney general in 2003 and was 6th District U.S. representative from 2004 through 2012, was asked how hard politically it would be to pass the $1-a-pack tax increase.

"We are not overly sanguine about it. We do live in Kentucky and I think we all understand that, but things are changing in Kentucky," he said, noting that there are only 4,500 tobacco farmers in the state, down from almost 60,000 in 1992. "You are seeing a lessening of the economic impact, a lessening of the number of people who benefit from tobacco, and I think all of those things ought to come together to make this a more propitious time to get these things done."

Alvarado said opponents of the tax acknowledge that its day will come. He noted the state's budget problems and said,"It will be an accomplishment with the largest health impact for our state, and that's why we have to keep chasing the prize as a group."

Chandler concluded, "Folks, we are not going away until we succeed. We are not going away until Kentucky's smoking rate is no longer the highest in the nation. We are going to keep at it until we win this battle because our work is a win for public health, it's a win for Kentucky's budget and it's a win for Kentucky businesses."

Tuesday, October 17, 2017

Trump has mixed messages on Obamacare subsidies deal; McConnell is noncommittal, and some in GOP oppose it

UPDATE, Oct. 18: White House Press Secretary Sarah Huckabee Sanders said Wednesday that President Trump is opposed to the deal as it now stands. Sen. Lamar Alexander said he expected the deal to become law by the end of the year.

"A pair of leading Republican and Democratic senators reached an agreement Tuesday to fund key federal health-care subsidies that President Trump ended last week — and the president expressed support for the plan," The Washington Post reports. But it remains to be seen whether Majority Leader Mitch McConnell, other Republican Senate leaders, and leaders of the House's Republican majority, would go along.

“We haven’t had a chance to think about the way forward yet,” McConnell said at his weekly news conference, "minutes after the deal was announced about 20 feet away outside a Republican policy luncheon," Sean Sullivan and Juliet Eilperin report for the Post.

Just last week, Trump cut off the subsidies, which reimburse insurance companies for reducing out-of-pocket costs such as co-payments and deductibles for lower- and moderate-income Obamacare policyholders. Tuesday, he said of the deal, “It’ll get us over this intermediate hump,” and called it “a short-term solution so that we don’t have this very dangerous little period.”

Insurers have said that without the subsidies, "premiums for many customers purchasing plans under the Affordable Care Act would shoot up, and with profits squeezed, some of the companies would probably leave the market," The New York Times reports. That could leave some counties, especially in rural areas, without any Obamacare insurers.

The deal between Sens. Lamar Alexander of Tennessee and Patty Murray of Washington, the Republican chairman and ranking Democrat of the Senate health committee, would give states more flexibility in Obamacare. For example, Alexander "said the proposal would offer states greater freedom by allowing them to make changes to insurance offerings as long as the plans had 'comparable affordability,' which is a slightly looser definition than the existing one."

"For Democrats, not only would the cost-sharing reductions be brought back, but millions of dollars would be restored for advertising and outreach activities that publicize insurance options available in the health law’s open enrollment period, which starts next month," the Times reports. "The Trump administration had slashed that funding."

“We will spend about twice as much or more than President Trump wanted to expend,” Alexander said. “This agreement avoids chaos, and I don’t know a Democrat or a Republican who benefits from chaos.”

But the path forward remained unclear. The House is in recess week, and a spokesman for Speaker Paul Ryan declined to comment, but some leading House conservatives objected to the plan, and Rep. Tom Cole (R-Okla.), a close ally of House GOP leaders, told the Post, “None of our guys voted for Obamacare. They’re not very interested in sustaining it.” UPDATE, Oct. 18: House Speaker Paul Ryan, "reflecting his most conservative members, came out against the deal on Wednesday," the Times reports.

Across the Capitol, "Many Republican senators are distancing themselves" from it, the Post reports. However, Thomas Kaplan and Robert Pear of the Times report: "Sen. John Thune of South Dakota, a member of the Senate Republican leadership, said there would be 'a sense of urgency to move a bill,' since Mr. Trump intended to stop the payments right away."

Neonatal Abstinence Syndrome conference to be held Nov. 10 at Northern Kentucky University; it's free, but registration is required

Northern Kentucky University is hosting a conference Nov. 10 that will convene researchers from across the Ohio River together to discuss neonatal abstinence syndrome: addicted babies.

The conference, which organizers hope will be an annual event, will be held from 9 a.m. to 4:45 p.m. in Room 107 of the NKU Student Union in Highland Heights.

The conference will focus on evidence-based research into neonatal abstinence syndrome, with the hope of increasing collaboration among NAS researchers.

Vice News chart
As part of a series of stories on opioid addiction called A Nation in Recovery, Keegan Hamilton of Vice News writes that NAS "has overwhelmed the medical system, and many intensive care units for newborns are at capacity." The rate of babies being born with NAS has increased 400 percent since 2000, with one baby born with the syndrome every 25 minutes. In Kentucky, one out of every 50 newborns has NAS.

The keynote speaker for the conference will be Judith Feinberg, a professor of behavioral medicine and psychiatry at West Virginia University, who will present "The Opioid Epidemic: A view from the Belly of the Beast."

Other topics include the state of research on NAS, and what is left to find out; what communities can do about the opioid epidemic; and opioids through the eyes of a physician.

Sam Quinones, author of Dreamland: The True Tale of America's Opiate Epidemic, will wrap up the day in a conversation led by NKU Provost Sue Ott Rowlands. In a visit to the campus last year, Quinones challenged the region to develop collaborative efforts to battle the opioid epidemic.

"As part of the response to that challenge, NKU has been leading the effort in working with universities to establish ORVARC,” Rowlands said in a press release.

Quinones was the keynote speaker at the most recent Foundation for a Healthy Kentucky policy forum, where he talked about the importance of re-building communities as part of the ultimate solution to the opioid epidemic.

"Heroin is the perfect symbol for how isolated we have become as Americans, and how much we have killed off or ignored what would bring us together," he said. "I believe therefore more strongly than ever that the antidote to heroin is not Naloxone, it is community."

Registration for the conference is free, but required. Click here to register. Click here for the conference schedule.

Monday, October 16, 2017

Surgeon and health researcher goes home to Appalachia to ask, 'Is health care a right?' and gets differing, evocative answers

Dr. Atul Gawande
"Is health care a right?"

So asks Atul Gawande, a surgeon and public-health researcher, in an article for The New Yorker, after asking it of people in his hometown of Athens, Ohio, in the foothills of Appalachia.

He found that even those who lean toward thinking health care is a right still struggle with the idea of "undeserving" people getting something for free. That means Medicaid, the main instrument of the Patient Protection and Affordable Care Act in Kentucky.

One middle-aged Ohio couple, who had private insurance with a $6,000 deductible and a hefty co-pay and premium, told Gawande that their many health issues had caused them to file for bankruptcy.

And while they both said they leaned conservative, the husband, called Joe, maintained that access to health care is a right, but shouldn't be free. But his wife, called Maria, was conflicted. She said her liberal side believes that "people should be judged by how they treat the least of our society," but her conservative side believes that because "I work really hard, I deserve a little more than the guy who sits around."

Gawande writes that "a right makes no distinction between the deserving and the undeserving," but said this concept "felt perverse" to Maria and Joe.

“I see people on the same road I live on who have never worked a lick in their life,” Joe told Gawande, his voice rising. “They’re living on disability incomes, and they’re healthier than I am.”

Joe stressed that he would be willing to help people who tryto help themselves, but had no desire to help a person who has "spent his whole life a drunk and a wastrel." Gawande writes that "such feelings are widely shared."

But not by everyone. Gawande's friend Tim Williams, a cancer survivor who went three years without a job after chemotherapy and now works as the operator of the town's water-treatment plant, told Gawande that health care is like water: necessary for human existence, and therefore the government has the responsibility to provide it.

Monna French, a 53-year-old librarian at the middle school in Athens, said she had largely taken care of herself and her two children after her divorce, and eventually landed a job at the library that offered health insurance. Calling herself a conservative, she said the idea of health care as a right is just another way to undermine work and responsibility. “If you’re disabled, if you’re mentally ill, fine, I get it,” she told Gawande. “But I know so many folks on Medicaid that just don’t work. They’re lazy.”

But when Gawande asked French and others about Medicare, the program for all people 65 and older, they were all on board -- largely because everyone who works pays into it. Medicaid, funded by federal and state taxes, is open in Kentucky to people with incomes up to 138 percent of the poverty line. At 139 percent, they must rely on private insurance, which they may not find affordable.

French, whose husband is on Medicare, told Gawande, “I believe 100 per cent that Medicare needs to exist the way it does.” Gawande writes, "This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get."

Gawande says this understanding could be the key to the current political impasse over Obamacare, because a system that gives everyone a different deal is having a "corrosive effect" on America. He drew insight from another childhood friend, artist Arnold Jonas, who pays his bills by working as a mechanic or manual laborer.

Jonas said he doesn't consider health care a right, but does think health policy should be centered around security. For example, he noted that the fire department and police provide security to all of us, and said health care should be the same -- through "collective effort and shared costs." However, he added, "When people get very different deals on these things, the pact breaks down."

Gawande also tells the story of a friend who had been opposed to Obamacare, but after having a heart attack realized the importance of its guarantee that insurance policies cover pre-existing conditions.

Gawande writes in detail about the history of health insurance; he notes the growing "gig economy" that has moved many Americans away from the traditional employer-insurance model; the move away from one of America's fundamental concepts of "shared belonging, mutual loyalty and collective gains;" the high cost of health care, and how that further divides the haves and the have nots; and the divisions that exist around what kind of health care America should have.

"Few want the system we have, but many fear losing what we've got," he writes, adding later, "What we agree on, broadly, is that the rules should apply to everyone."

Sunday, October 15, 2017

Registration is open for Covering Health: a News Workshop, free of charge to all journalists, in Madisonville Friday, Nov. 10

On Friday, Nov. 10 in Madisonville, the Institute for Rural Journalism and Community Issues and the Foundation for a Healthy Kentucky will present the latest in their series of workshops to help local journalists cover health care and health in Kentucky.

The presenters will include Al Cross, director of the institute and editor-publisher of Kentucky Health News; KHN reporter Melissa Patrick, a former nurse; Dr. Ellen Hahn of the University of Kentucky College of Nursing, who directs the Bridging Research Efforts and Advocacy Toward Health Environments (BREATHE) program; and Wayne Meriwether, CEO of Twin Lakes Regional Medical Center in Leitchfield, a leader of the Population Health Committee in Grayson County.

"Covering Health: A News Workshop" will run from 9:30 a.m. to 4 p.m. at the Ballard Convention Center, near the KY 70 interchange with Interstate 69 (formerly the Pennyrile Parkway). Lunch will be served, and the event will be free of charge, thanks to support from the foundation.

"We hope many reporters and editors who cover Western Kentucky will spend a few hours with us to learn how their reporting can help their readers, listeners and viewers live healthier lives and better understand the health-policy debates going on in Frankfort and Washington," Cross said. "We also invite their suggestions for the program."

The program will include:
  • Information about the major health issues facing Kentucky, with special attention to Western Kentucky and the counties represented by the attendees
  • An explanation of the Medicaid program and the changes that the administration of Gov. Matt Bevin wants to make (and which may be federally approved by Nov. 10)
  • An explanation of health insurance under the Patient Protection and Affordable Care Act ("Obamacare") and the issues in play in Congress and the Trump administration
  • How to gather and use health data on your county to do stories that help your readers, viewers and listeners realize the depth of the health issues facing your community
  • How drug abuse has become less of a law-enforcement issue and more of a health issue, and the issue of syringe exchanges to prevent outbreaks of HIV and hepatitis C
  • The impact of tobacco on Kentucky's health and the issues around local and state laws to limit smoking
  • How a local health coalition in Grayson County won passage of smoke-free ordinances
  • How to cover local health issues, including your health department, health board and hospital
While the workshop is free, registration is required, and the deadline is Friday, Nov. 3. To download a registration form, click here. For a report on last year's workshop, in Eastern Kentucky, click here.

Congress helped drug manufacturers loosen federal oversight of opioid shipments, '60 Minutes' and The Washington Post report

After years of being lobbied by drug manufacturers, Congress last year stripped the Drug Enforcement Administration of its most effective tool to police drug distributors, “even as the opioid epidemic raged and thousands of Americans were dying of overdoses.” So says The Washington Post, introducing its report of a joint investigation with CBS's “60 Minutes” found.

"A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills," the Post reports. "The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns."

The CBS report says Kermit, W.Va., pop. 392, just across the state line from Warfield, Ky., received 9 million hydrocodone pills over three years. The main distributor in Mingo County was Miami-Luken Inc. of Springboro, Ohio. "Many went to one pharmacy in Williamson, the county seat, population 2,924," the Post reports. "In one month alone, Miami-Luken shipped 258,000 hydrocodone pills to the pharmacy, more than 10 times the typical amount for a West Virginia pharmacy. The mayor of Williamson has since filed a lawsuit against Miami-Luken and other drug distributors, accusing them of flooding the city with pain pills and permitting them to saturate the black market."

Sen. Joe Manchin (D-W.Va.) has asked Trump to withdraw Marino's nomination of the bill's prime sponsor, Rep. Tom Marino (R-Pa.) to be director of the White House Office of National Drug Control Policy, or drug czar. Manchin said he was "horrified" by the Post-CBS report. "Marino’s staff called the U.S. Capitol Police when the Post and '60 Minutes' tried to interview the congressman at his office on Sept. 12," the Post reports.

The bill requires the DEA to show that a “substantial likelihood of an immediate threat” of death, serious bodily harm or drug abuse before it can freeze drug shipments. It passed the House and Senate by unanimous consent, a non-debating procedure usually "reserved for bills considered to be noncontroversial," the Post reports.

"The White House was equally unaware of the bill’s import when President Barack Obama signed it into law, according to interviews with former senior administration officials." However, the Post and CBS report that Attorney General Eric Holder warned that an earlier version of the bill would undermine DEA's ability to block suspicious drug shipments. Obama and Loretta Lynch, attorney general at the time, declined to be interviewed.

Joe Rannazzisi, former DEA official (CBS News photo)
Near the start of the process, Joe Rannazzisi, who ran DEA's program to keep drugs from being diverted for illegal purposes, told congressional staffers, "You'll be protecting criminals." DEA's already poor relationship with Congress went downhill, the bill passed the House, the DEA administrator resigned for unrelated reasons, Rannazzisi lost his job, and the agency "was forced to accept a deal it did not want" in the Senate, CBS reports. "The new law makes it virtually impossible for the DEA to freeze suspicious narcotic shipments from the companies."

The bill was steered through the Senate by Sen. Orrin Hatch of Utah. It was drafted by a former DEA lawyer who went to work for drug companies and now works for Cardinal Health, the distributor that pushed back earliest and hardest on DEA enforcement efforts. DEA had fined Cardinal Health and McKesson Corp. millions for filling suspicious orders. AmerisourceBergen is the other major drug distributor in the U.S. CBS's Bill Whitaker asked Rannazzisi, "These big companies knew they were pumping drugs into American communities that were killing people?" Rannazzisi replied, "That's a fact. . . . This is an industry that's out of control."

The Post reports, "The DEA and Justice Department have denied or delayed more than a dozen requests filed by the Post and '60 Minutes' under the Freedom of Information Act for public records that might shed additional light on the matter. Some of those requests have been pending for nearly 18 months. The Post is now suing the Justice Department in federal court for some of those records."

October is health literacy month, and the revived Health Literacy Kentucky wants you to know it's a topic that affects everyone

By Melissa Patrick
Ketnucky Health News

Most states do not have have an organization dedicated to health literacy, but Kentucky does, and it's spending 2017 re-branding itself and letting Kentuckians know what it offers.

Health Literacy Kentucky is a statewide coalition of volunteers who work toward improving the state's health outcomes through improved health literacy.

"Health literacy affects everyone and is critical in helping us make choices for the best health that we can -- for ourselves and for our family and friends," Charles Jackson, The Humana Foundation's consultant for the initiative, said in an interview with Kentucky Health News.

Jackson, who is also the head of the HLK steering committee, noted that the American Medical Association says "Health literacy is a stronger predictor of health than age, income and employment status, education or race."

HLK's website says the impact of low health literacy is well-documented. It says people with poor health literacy have overall poorer health, higher rates of emergency-department use, lower use of preventive services and increased difficulty managing their chronic conditions. It adds that poor health literacy cost the nation up to $238 billion every year.

HLK was founded in 2009 and has focused most of its past efforts and resources hosting an annual health literacy conference that largely targeted health care providers. But this year, Jackson said it's working to re-brand itself and increasing public awareness -- and it also has a new partner.

In June, HLK signed a memorandum of understanding with the Center for Health Service Research at the University of Kentucky, which will now house the organization and offer it administrative and operational support. Center Director Mark Williams, who has done research on health literacy since 1990, said they expect this partnership to be a "powerful" one.

"Health literacy encompasses far more than just literacy. It represents an individual’s ability to obtain and use health information to make decisions," Williams said. "Through this partnership with Health Literacy Kentucky, the UK Center for Health Services Research can support efforts to work with patients, their family caregivers and community providers to address health literacy education and research."

Jackson noted that one of their first efforts as partners will be to conduct a heath-literacy needs assessment of health professionals to help inform future HLK strategies.

Another new initiative for the organization is its first Kentucky Health Literacy Award, of which it will soon call for nominations. The award will be presented at the Dec. 5 Kentuckiana Health Collaborative forum in Louisville, which will focus on health literacy. The results of the needs assessment survey will also be announced at this forum.

Elizabeth Edghill, who is also on HLK's steering committee, says the need for health literacy is "profound" for everyone.

"We need to recognize that it's not about education, it's not about income or language barriers," she said. "Those are all huge contributors and of course they can make one at higher risk for low health literacy, but I really think we have to use what we call a universal precaution approach. We need to assume that anyone can be having a low health literacy moment at any encounter and treat them respectfully and with good communication."

Edghill is a registered nurse who is the manager of refugee and immigrant services for Family Health Centers in Louisville. Along with a co-worker, she has initiated several health-literacy programs, including one for all of the center's patients; one that involves a patient advisory group that helps create better health related materials, and another that focuses on health-insurance literacy.

Asked how individuals could immediately improve their health literacy, Edghill said: "One of the most important ways to improve your health literacy is to find a way to record the information."

Edghill told a story illustrating how three people can hear the same health information from a health-care provider and leave with three different interpretations. She offered several suggestions on how to record information, including asking the provider if you can record the conversation; taking notes during the visit; taking someone with you to listen and take notes; or to make sure you understand the after-visit summary that is often provided before you leave the office.

Edghill has been named the 2017 Medi Star Dickinson Wright Nurse of the Year, an award  she will receive Oct. 24 in Louisville.

Jackson said health departments and libraries are great resources to improve health literacy. "Those are the kind of resources we want people to feel comfortable using," he said.

He also noted some free online resources, which he said are important for areas with poor access to health care. They include "Learning About Diabetes;" "The Depression and Bipolar Support Alliance;" and another for children who are overweight or obese called "Weigh2Rock."

Also, the HLK website offers resources for individuals and communities, a "tools for teaching" page, a free online course with continuing-education credits, and training for health-care providers.

Williams noted that the UK Center for Health Services Research was awarded a $4.5 million grant in July to identify and address the social determinants of health in 27 Appalachian counties and parts of Louisville Metro. He said that after determining the most vulnerable patients in these areas, the researchers will then  identify their unmet social needs that contribute to poor health, like unstable housing or a lack of transportation, and then connect them with  community resources to meet these unmet needs.

"This is related to health literacy," he said, "because these patients on their own don't have the health literacy skills to be able to find these resources which could help them personally, and that results in improved, overall health."