Health reform should make Medicaid and Medicare more interested in preventing chronic diseases in young, expert says

Dr. Wayne Myers

While some rural areas may not have enough doctors (or those who accept Medicaid patients) to treat new patients generated by federal health reform, the key to healthy living is more education, not more physicians, rural medical expert Dr. Wayne Myers opines in The Rural Monitor. As an example, Myers points to Hazard and Perry County, where he once worked. The Appalachian county leads the nation in shortest average life span for women (72.65 years) and is third shortest for men (66.52 years) despite having an abundance of doctors and health facilities. The reason, Myers says, is bad habits that lead to unhealthy lives, something no amount of medical attention can cure.

"In Perry County, as in much of America, medical care is losing to unhealthy behavior," Myers writes. "Clinicians aren’t trained, nor is our clinical system structured, to accomplish changes in long-term cultural behavior, or to respond to the needs of groups of people. Certainly the 15-to-20-minute acute-care visit is a poor situation to try to work with a person on diet, level of activity, his/her addictions. We can’t modify family and social patterns with tools developed to treat strep throat, sprained ankles or breast cancer."

Myers, who headed the federal and Kentucky rural-health offices, said the solution is education at the local level, with "a lot more health educators, community health nurses and nutrition educators" that are trained within the community. Areas with community colleges can build partnerships with schools to receive training, he suggests. His hope is that the Patient Protection and Affordable Care Act will provide the resources and motivation necessary to bring about changes.

As the law generates enrollees, the Center for Medicare and Medicaid Services’ "book of business will shift from old people on Medicare toward younger people on Medicaid," he writes. "When the main business of CMS was Medicare, the rational business strategy was to seek the most economical quality care for those with only a few years to live. As the business shifts toward Medicaid and subsidized private insurance customers, the rational business strategy for CMS shifts toward preventing chronic disease. From an insurer’s point of view, a 70-year-old obese hypertensive diabetic is a self-limited problem. She’ll die soon. A 30-year-old with the same diagnoses will be a very long-term financial drain.  It will be good business for CMS to keep their 'covered lives' healthy."

This, he said, is kind of forward thinking we need to ensure young Americans get healthy. "We need new approaches to keeping people healthy, instead of trying to heal them after they get sick," Myers writes. "Clinicians can’t change the way people live and raise their kids, even if some of the choices the parents make turn out to be pretty dangerous for the kids. These are sensitive life and death issues. We need to tackle them." (Read more)

Federal budget deal targets Medicare payments, and that means Kentucky hospitals won't be happy

Looking for a way to localize the budget deal announced by congressional negotiators last night? Call up your local hospital.

David Rogers of Politico reports that hospitals are "furious with the fact that the deal offers no relief from future cuts on Medicare providers – and even extends these annual 2 percent reductions into 2022 and 2023." The cuts would be a continuation of those imposed by the "sequester" legislation that took effect when Congress failed to reach an anticipated deal on the federal deficit and taxes.

The $28 billion extension of the cuts, almost a third of the $85 billion total, "helps to dress up the package with tens of billions in savings, but at a time when hospital networks are already feeling the impact of health-care reform, there is a fear that Congress is not seeing the long term impact of these budget assumptions," Rogers writes.

Most rural hospitals are already facing Medicare cuts because reform law reduces the extra payments made to hospitals that have large percentages of Medicare patients. Those hospitals are disproportionately rural.

The deal also includes "a provision that aims to prevent fraud and abuse in the Medicaid program for the poor and disabled," Modern Healthcare reports. "According to a summary, the provision allows states to delay paying for suspect claims as long as the delay does not harm a beneficiary's access to care. It also would allow states to collect medical child support in cases where health insurance is available from a non-custodial parent and allows Medicaid to recoup costs from beneficiary-liability settlements."

Why cut Medicare payments? "Congressional staffers were not prepared to talk about the cuts on the record, but said it boiled down to Medicare providers being the least painful target. Democrats, they noted, have not traditionally been strong supporters of preserving the payments to providers, being much more concerned with maintaining funds for beneficiaries. Republicans saw extending for two years cuts that are already in the law for mandatory programs as a simple way to add deficit reduction to the replacement of sequestration for discretionary programs," Michael McAuliff reports on The Huffington Post.

Kentucky's health-insurance exchange has covered a greater share of population than any other state-based exchange

Kentucky has registered more people for Medicaid and private health insurance than any other state with its own exchange created under the federal health-reform law, Christine Vestal reports for Stateline, in a story explaining why Kynect and some other state exchanges are working well.

“Our system doesn’t have a lot of bells and whistles,” Carrie Banahan, executive director of the Kentucky Health Benefits Exchange (the formal name of Kynect), told Vestal. “There aren’t a lot of graphics that would take a lot of bandwidth.”

"Kentucky and other top-performing states enable consumers to browse the various plans available on the exchange without first having to set up a password-protected account," Vestal notes. "That step alone spared those exchanges a lot of error messages and screen freezes experienced by people using the federal site," Healthcare.gov.

"Successful states also devoted months, not weeks, to exhaustive, round-the-clock testing," Vestal writes. "Kentucky tested for three months, while the U.S. Department of Health and Human Services reportedly devoted only the last two weeks of September to testing Healthcare.gov before its Oct. 1 launch."

The four most successful states – Connecticut, Kentucky, Rhode Island and Washington – all contracted with the consulting firm Deloitte "to manage and develop their sites," using federal funds, Vestal reports. Kentucky's expenses for its exchange were higher than average. (Stateline chart)

UPDATE: As of 7 p.m. Thursday, Dec. 5, after 10 days of increased traffic and enrollments, the exchange said it had enrolled 71,955 people, 56,437 of them in Medicaid and 15,518 in private plans. Most of the 28,307 who had been found eligible for a subsidy to buy a private plan had not chosen a plan yet. Dental plans had 5,074 enrollees.

Beshear's office says he is considering 'various ideas' for financing Ky. insurance exchange, not just a 1% fee on policies

"Gov. Steve Beshear’s administration is reconsidering how to pay for the Kentucky Health Benefit Exchange amid increased criticism from some Republicans in the legislature and a court case challenging a fee Beshear created through executive order," Ryan Alessi reports for cn|2's "Pure Politics," a service of Time Warner Cable.

“Various ideas for a sustainability plan for the exchange are being discussed, and such a plan will be finalized for implementation before current funding expires in 2015,” the governor's office told Alessi. Current funding comes from the federal government.

Beshear's plans have called for the exchange to be financed with a 1 percent fee on policies bought through the exchange, to be paid by insurance companies using it. "But in a statement in response to questions from Pure Politics, the governor’s office said it’s suddenly considering other ways to pay for the exchange," Alessi reports, adding that the office didn't respond to his follow-up question about whether legislative approval would be needed for whatever plan was adopted.

House Speaker Greg Stumbo, a Democrat from Prestonsburg, said during a Kentucky Hospital Association panel last month that the fee does not require approval of the General Assembly. Senate Health and Welfare Committee Chair Julie Denton, R-Louisville, told Alessi that it does. Here's a video clip:

Feds say reform law has saved Kentuckians on Medicare an average of $928 this year on prescription drugs

The federal health reform law has saved seniors and the disabled millions of dollars on their Medicare prescription-drug coverage, says the Centers for Medicare & Medicaid Services.

CMS said 65,040 Kentuckians have saved a total of $60.4 million in the first 10 months of 2013, an average of $928 per person in Medicare. CMS said Kentucky seniors have saved $180.9 million on the coverage, known as Part D, since the passage of the reform law.

Seniors will also be free to use more of their Social Security cost-of-living adjustment as they choose, because the Medicare Part B premium will not increase in 2014 as a result of the law’s cost restrictions, CMS noted. The deductible for standard Part D plans will decline by $15 in 2014, to $310.

The data also show that since the Patient Protection and Affordable Care Act took effect, more than 7.3 million seniors and people with disabilities who reached the prescription coverage gap, commonly known as the "donut hole," have saved $8.9 billion on their prescription drugs, an average of $1,209 per person.

The "donut hole" is the gap in coverage after the basic coverage and before the catastrophic coverage takes effect.  Without rebates authorized by the law, Medicare beneficiaries would have to pay out-of-pocket for the entire cost of prescription drugs once they hit the hole, until they incur enough expense to reach catastrophic coverage.

Next year, Medicare Part D participants in the donut hole will save about 53 percent on the cost of brand name drugs and 28 percent on the cost of generic drugs, CMS says. These savings and Medicare coverage are to gradually increase until 2020, when the donut hole will be closed.

Ky. Hospital Association defends 'critical access' designation that gives small, rural hospitals a federal financial boost

The Kentucky Hospital Association came out strongly for continued federal support of small, rural hospitals Thursday, objecting to a proposal that the "critical access hospital" designation be based entirely on distance from other hospitals. Kentucky has 29 such hospitals, which get slightly higher Medicare and Medicaid reimbursements in return for limiting their size and services.

Until 2006, states were allowed to make the designation based on a community's health status, poverty rate, rural nature and other factors. So many were designated that they became the majority of critical access hospitals. That is also the case in Kentucky.

The Office of Inspector General of the U.S. Department for Health and Human Services said in August that the government could save up to $1 billion a year if the designation were limited to the original criterion, being at least 35 miles from another acute-care facility, or 15 miles in mountainous areas. KHA's initial repsonse is here.

"The OIG report seeks to eradicate rural health care by shutting down rural hospitals," said Charles Lovell, CEO of Caldwell Medical Center, a critical access hospital in Princeton. "People call us Band-Aid stations," but he could provide a long list of lives saved at his hospital, he said. Other speakers cited hospitals' important role in providing jobs and recruiting doctors for small towns. Cutting the list "would only hurt our communities' physical and economic health," said Susan Starling, CEO of Marcum and Wallace Hospital in Irvine.

Fran Feltner, director of the University of Kentucky Center of Excellence in Rural Health, noted that it was National Rural Health Day and said, "I believe every Kentuckian should have access to the right care at the right time, and close to home."

Critical access hospitals make up only 22 percent of Kentucky hospitals, but maintaining their extra reimbursement would also help the chains that own some of them, because costs of the chain can be allocated to individual hospitals. Here are the critical access hospitals in Kentucky, by county:
Allen: The Medical Center at Scottsville
Breckinridge Memorial Hospital, Hardinsburg
Caldwell County Hospital, Princeton
Carroll County Hospital, Carrollton
Casey County Hospital, Liberty
Cumberland County Hospital, Burkesville
Estill: Marcum and Wallace Hospital, Irvine
Floyd: McDowell Appalachian Regional Hospital; Saint Joseph Martin
Grant: St. Elizabeth Medical Center Grant County, Williamstown
Green: Jane Todd Crawford Hospital, Greensburg
Hart: Caverna Memorial Hospital, Horse Cave
Knox County Hospital, Barbourville
Leslie: Mary Breckinridge Hospital, Hyden
Lincoln: Ephraim McDowell Fort Logan Hospital, Stanford
Livingston Hospital and Healthcare, Salem
Madison: Saint Joseph Berea
Marshall County Hospital, Benton
Mercer: James B. Haggin Memorial Hospital, Harrodsburg
Morgan County Appalachian Regional Hospital, West Liberty
Nicholas County Hospital, Carlisle
Ohio County Hospital, Hartford
Owen: New Horizons Medical Center, Owenton
Russell County Hospital, Russell Springs
Simpson: The Medical Center at Franklin
Trigg County Hospital, Cadiz
Union: Methodist Hospital Union County, Morganfield
Wayne County Hospital, Monticello
Woodford: Bluegrass Community Hospital, Versailles

Free-for-all food program increases student participation, raises Ky. breakfast count by 25% with only 39% of districts participating

Kentucky schools participating in a program that provides free breakfast and lunch to all students in high-poverty schools have significantly increased student participation in school lunch and breakfast programs, Charles Edwards reports for Education Week.

Schools participating in the "community eligibility option" have increased student participation by 13 percent in the lunch program and 25 percent in the breakfast program during the first two years of its availability and eliminated significant administrative costs, according to the Washington-based Food Research Action Center and the Center on Budget and Policy Priorities.

Collectively, Illinois, Kentucky and Michigan achieved a 25 percent increase in breakfast participation over the first two years, Education Week reports.

Of the 174 school districts in Kentucky, 68 participate in the community eligibility option, Nancy Rodriguez of the Kentucky Department of Education told Kentucky Health News. That is 39 percent of the public school districts. One private school also participates.

The program allows high-poverty schools to serve all students free breakfasts and lunches without individually identifying children as eligible. Schools get about the same amount of reimbursement from the Department of Agriculture that they did under the existing system—but without the paperwork. The reimbursement is based on the total number of meals served.

The school nutrition director at Ballard County, a participant in the "community eligibility option," told Whitney Jones of WKMS-FM, Murray State's NPR station, that the district saves $500 per year per student eating both breakfast and lunch at school.

The traditional way to determine eligibility for free or reduced breakfast and lunch required families to fill out a parent-income survey, which discouraged some from enrolling. The new eligibility option has been rolled out incrementally since it was authorized by Congress in 2010, and all eligible schools in the country may participate beginning in the 2014-15 school year.

Now, the percentage of a school's children who are already enrolled in other federal need-based program or are homeless, migrant, in Head Start or in foster care, determines the eligibility of the school, reports Edward. If a school has an enrollment of at least 40 percent of such directly certified children, it is eligible. Some districts combine all their schools to include those that are below 40 percent.

Participation in the program has exceeded the original expectations, with more than 2,200 schools signed up in the first seven states allowed to participate. The original projection estimated 300 schools would participate over 10 years, Education Week reports.

Nationwide, eyes on are Ky.'s implementation and debate about Obamacare, and thousands of Kentuckians are signing up for it

By Molly Burchett
Kentucky Health News

The good, the bad and the ugly about health reform in Kentucky are showing up on national news as the state's two Republican senators stand vehemently against Obamacare and the state's Democratic governor ardently roots for it. Meanwhile, state officials say their health-insurance website, which is working much better than the federal site, is getting much more traffic than they expected.

The Republican senators from Kentucky, Rand Paul and Minority Leader Mitch McConnell, declared last week that their constituents didn’t want any part of the Affordable Care Act. “Obamacare might sell in New York, but Kentuckians aren’t buying it,” McConnell and Paul wrote in a column sent to newspapers.

This came after Democratic Gov. Steve Beshear, who decided to build the insurance exchange without asking for approval from the politically divided General Assembly, wrote a New York Times op-ed in support of the reform law. He jabbed at “naysayers” who “pour time, money and energy into overturning or defunding the Affordable Care Act.”

The problem for McConnell and Paul is that Kentuckians are buying into Obamacare, writes John Tozzi of Bloomberg Businessweek. "In fact, the Kentucky exchange has, so far, enrolled more patients than any other." Kentuckians are enrolling in droves, at a rate of more than 1,000 people per day, and Beshear has become more pointed in his criticism of McConnell and Paul.

“Our state’s U.S. senators are simply ignoring the facts when they continue to insist that ‘no one’ in Kentucky wants the Affordable Care Act,” Beshear told MSNBC.

Carrie Banahan, executive director of Kynect, the state's insurance exchange, told Jane Timm of MSNBC that enrollements are far beyond state officials' expectations. “We had thought that maybe we might receive a couple of hundred applications during the month of October. We had no idea it would be thousands of applications.”

Kynect's Carrie Banahan (left) and Gov. Steve Beshear

There were concerns that people in rural areas might not get the word about the program or have difficulty signing up because they lack Internet access, but Teresa Fleming, chief financial officer of Mountain Comprehensive Health in Eastern Kentucky, told Timm her lobbies had been flooded with people signing up for the plans. Her primary-care facilities were among the numerous Kentucky clinics that received part of $2.83 million in federal money for Kynect outreach and enrollment iniatives.“The response has shocked us,” Fleming said, “We think it’s due to a lot of word of mouth."

Kentucky's success is getting much national attention. Beshear discussed it with MSNBC’s Chris Matthews and keynoted a meeting in Washington. President Obama praised Beshear’s implementation during a private meeting with House Democrats Wednesday, said Rep. John Yarmuth, D-Louisville, who was at the meeting.

“The president said (the Affordable Care Act) got really good rollouts in some places you wouldn’t expect it, and he said the place that has done best is Kentucky,” Yarmuth told James R. Carroll of The Courier-Journal. He said Obama noted the irony that McConnell and Paul have been two of Obamacare's most vocal critics.

Republican efforts to defund or delay Obamacare led to the shutdown of the federal government, which has proven highly unpopular. It may have also improved public opinion of the law; an NBC/Wall Street Journal poll last week found a 7-percentage-point increase in its popularity. The survey also found the Republican Party registering its worst approval ratings in the poll's history, with just 24 percent having a favorable opinion of the GOP, and 21 percent viewing the Tea Party favorably.

"There is little question that the GOP is bearing the brunt of blame in the standoff over re-opening the government and the debate over the debt ceiling as 53 percent of the public now places the blame on Congressional Republicans compared to 31 percent who view President Obama as being the guilty party," Rick Ungar of Forbes reports.

Federal shutdown won't stop Obamacare, Ky. insurance exchange

By Molly Burchett
Kentucky Health News

The federal government is on the brink of shutdown after House Republicans refused to pass a budget unless it involved a delay in the health reform law, and both Senate Democrats and the White House have said they will block any such budget resolution. In the event that Congress doesn't reach a compromise, which would lead to a shutdown on 12:01 a.m. on Tuesday, enrollment for Kentucky's online health insurance exchange, Kynect, will still begin as scheduled.

The shutdown drama is heightened since Tuesday is both the start of the federal fiscal year and the first health insurance can be bought on the online exchanges created by the reform law, often called Obamacare. Kynect won't be affected because it is funded by a "permanent appropriation," that isn't subject to annual appropriation, Paul Van de Water, a policy analyst at the Center on Budget and Policy Priorities, told Sharon Begley of Reuters.

The Department of Health and Human Services' contingency plan for a government shutdown makes clear that Obamacare will continue, along with other mandatory programs like Medicaid and Medicare, programs that do not rely on annual appropriations and involve the human life and safety, Cunningham and Nather report. "And that means the staff that carry out mandatory programs like those in the health law can keep working — even if their positions are funded through the annual spending bills."

However, uncertainty about the shutdown could add more confusion to America's lack of understanding of the health law. Many may not realize they can sign up for coverage through the state exchanges even if the federal government is shut down.

The Kaiser Family Foundation's August 2013 Health Tracking Poll showed that roughly four in 10 Americans, 44 percent, either think the law has been repealed by Congress or overturned by the Supreme Court. A recent Pew Research Center poll last week found 53 percent of Americans disapprove of the law, and 42 percent approve.

But most Americans oppose defunding the new law if it means shutting down the government and defaulting on debt, says CNBC's third quarter All-American Economic Survey.

President Obama has said he will not negotiate on his signature legislative accomplishment, and most Senate Republicans have disavowed the House Republican strategy of risking a government shutdown.

The stakes are high for both political parties, writes Noam Levey of the Los Angeles Times. For Democrats, a meltdown of the new system would be politically damaging. For Republicans, "A relatively drama-free rollout of the law this fall could shatter what has been a key pillar of the Republican agenda."

Opinions about Obamacare will not change overnight and the law's effectiveness won't be determined by the first few weeks of the exchanges. The Congressional Budget Office estimates that only about 7 million people will enroll in 2014, but that the number will rise to 25 million by 2018.

There are currently 640,000 uninsured Kentuckians, which 14.9 percent of the state's population, says the Kynect website. About 332,000 will be able get insurance through the exchange, and 276,000 of them can get subsidies to buy insurance coverage through the exchange.  An additional 308,000 Kentuckians will be newly eligible Medicaid, with expansion of the program to people earning up to 138 percent of the federal poverty level.

It is expected that about 147,000 Kentuckians who are newly eligible for Medicaid in 2014 will find coverage through Kynect. That number is projected to increase to about 188,000 by 2021, says a Medicaid expansion report. Open enrollment for coverage runs through March 31, 2014. Beginning Jan. 1, coverage purchased on the exchange will take effect, and most Americans will be required to have health insurance or pay a penalty. Click here for more information about Kynect.

Gov. Steve Beshear and Lt. Gov. Jerry Abramson are appearing at events across the state this week to promote the exchange and enrollment, starting Tuesday morning in Louisville and that afternoon in Hazard. They will visit Ashland, Lexington, Covington and Bowling Green on Wednesday; and Mayfield and Owensboro on Thursday. For details, click here.

Delaying individual mandate, as GOP now proposes, would wreck exchanges and Obamacare, Democratic aide warns; McConnell says Republicans can't get Democratic votes they need in Senate

The key piece of the latest House Republican legislation to keep the federal government running – a one-year delay of the federal health-reform law and its requirement for individuals to make sure they are covered – "would have serious consequences" for the online health-insurance marketplaces set to open Tuesday, writes the spokesman for the only Democrat in Kentucky's congressional delegation.

"If you require insurance companies to cover everyone regardless of pre-existing conditions and don't require everyone to have insurance, the insurance companies will leave the market," writes Stephen George, communications director for Rep. John Yarmuth of Louisville. "Kentucky tried that in 1994, and the results were devastating: 40 insurance companies left the state, leaving just one private plan and one state-run plan." Supreme Court Justice Ruth Bader Ginsburg noted that in her concurrence to the decision upholding the law, George notes.

Senate Republican Leader Mitch McConnell told Newsmax.com that the House plan "would be a very appealing vote to all Senate Republicans," but they despair of getting any Democrats to join them. "It would require at least five Senate Democrats to agree with that. We’re not going to be able to do anything Republicans-only in the Senate because we have a math problem."

Hinting that the game is about at an end, or at least that he wishes it to be, McConnell said Republicans would target four Democratic senators who are seeking re-election next year in states President Obama lost twice: Mark Begich of Alaska, Mark Pryor of Arkansas, Mary Landrieu of Louisiana, and Kay Hagan of North Carolina.

"There are four Democratic senators who are running for re-election who will have to explain to their constituents why they didn't take the opportunity today to defund, and therefore stop, this overwhelmingly unpopular law," McConnell said. "Our ability to have achieved the defunding is not there, because we don't have enough Republican senators to achieve the goal — and until we have at least four or five Democrats to support us, we can't get that job done." (Read more)

Republican lawmaker says state should switch to block-grant system for Medicaid

Democratic Gov. Steve Beshear has argued that his expansion of Medicaid under federal health reform will improve Kentucky's health, but a freshman Republican legislator with experience in state health policy says a whole new approach would do much more for less money, providing funds that could be used to help Kentucky's mental-health agencies or to provide education, public protection and other services.

Rep. Robert Benvenuti

Rep. Robert Benvenuti of Lexington, former inspector general of the state Cabinet for Health and Family Services, told Ryan Alessi of cn|2 that the state could improve Medicaid with a block-grant system, which  could be implemented through a federal waiver. It would effectively end the open-ended approach to Medicaid, meaning that rather than paying a set amount per enrollee, states would be provided with annual lump sums and be free to run the program as they wanted, reports Kaiser Health News.

Republican governors have long lobbied for this flexibility, saying that it would result in a cheaper, more effective program, but the Democratic governor of New York, the independent governor of Rhode Island (who will run for re-election as a Democrat) and the Republican governor of Indiana have been granted waivers to implement a block-grant system, and their results suggest such system could improve Medicaid. Indiana used its waiver to introduce subsidized health savings accounts, which increased satisfaction rates for Medicaid enrollees to 94 percent by granting them more control over their own health dollars, reports Avik Roy of Forbes magazine, writing that Rhode Island saved $1.34 billion from 2008 to 2010, "an astounding figure for such a small state."

Benvenuti said Kentucky's current blanket-coverage system "doesn't provide any incentive with co-pays and deductibles to get the person with diabetes to be more careful about their weight, to manage their diabetic condition better. . . . The more we say we are simply going to blanket our commonwealth with Medicaid recipients, then the less we'll have to target what ultimate will be the solutions: education and true management of health."

A block-grant system provides flexibility to address Kentucky's specific needs, says Benvenuti. “You would then have money to say ‘In Kentucky, what are our health issues?’ And we could drive centers of excellence in cardiac care, in drug addiction and mental health much deeper into our commonwealth, much more at a grassroots level and provide that care,” he told Alessi. The cabinet declined to comment.

Throughout his career as a health-care attorney and work with numerous health systems, Benvenuti has focused on fraud and abuse as well as other operational and regulatory issues facing health-care providers. As the cabinet's inspector general, he led "investigations involving more than 3,000 health care facilities and services" across the state, says his website. Here's his interview with Alessi:

Mayors and AMA say food stamps shouldn't pay for soft drinks

Louisville's Greg Fischer is among 18 mayors asking Congress to ban sugary drinks from purchase under the Supplemental Nutrition Assistance Program, commonly called food stamps.  One day after their June 18 letter, the American Medical Association adopted a policy supporting the removal of sugar-sweetened drinks from SNAP.

In a the letter sent to congressional leaders, the mayors said it is "time to test and evaluate approaches limiting" the use of the subsidies for sugar-laden beverages to fight obesity and diseases linked to obesity, reports Jennifer Peltz of The Associated Press.

At its annual meeting, the AMA took several steps toward controlling the country's increasing obesity problem, including calling obesity a disease, an action that may prompt insurers to cover medical treatments aimed against obesity. “The AMA is working to improve the nation’s health care outcomes, particularly cardiovascular disease and diabetes, which are often linked to obesity,” said AMA President Dr. Ardis Hoven of Lexington. “Removing sugar-sweetened beverages from the Supplemental Nutrition Assistance Program will help encourage healthier beverage choices.”

This isn't the first attempt to ban soda from SNAP. The Department of Agriculture, where the program is housed, turned down such a request from New York City's Mayor Michael Bloomberg in 2010. The city had proposed a two-year experiment to see if a sugary beverage ban would reduce obesity among food-stamp recipients. But, the department rejected the plan and said a soda ban would “perpetuate the myth” that food stamp users make poor shopping decisions, The New York Times reported. Read about Kentucky's SNAP program here.

The soda lobby, the American Beverage Association, said sugary drinks shouldn't be singled out as a cause of obesity. It called obesity "a complex health condition that affects Americans of all income levels." Last year, more than 47 million low-income Americans used food stamps.

Read more here: http://www.kentucky.com/2013/06/18/2683656/18-mayors-limit-use-of-food-stamps.html#storylink=cpy

Read more here: http://www.kentucky.com/2013/06/18/2683656/18-mayors-limit-use-of-food-stamps.html#storylink=cpy

Beshear looks likely to announce that he will expand Medicaid

Gov. Steve Beshear appears likely to announce tomorrow that he will expand Kentucky's Medicaid program to people in households with incomes up to 138 percent of the federal poverty level, under federal health-care reform.

The notice of the governor's news conference about "Decision regarding Medicaid expansion" says it will be held in the ornate State Reception Room on the second floor of the state Capitol, an unlikely venue for an announcement that would disappoint so many of his natural allies in the Democratic Party. And Rep. Tom Burch, D-Louisville, chairman of the House Health and Welfare Committee, reiterated his February prediction that Beshear would expand Medicaid, cn|2 reports.

Under health reform, the federal government would pay all the cost of the estimated 400,000 newly eligible Kentuckians in Medicaid in 2014, 2015 and 2016. The state would pay 3 percent of the added cost in 2017, rising to 10 percent in 2020. Beshear has said the state should expand Medicaid if it can afford it.

Some Republicans have said the state can't afford it, but national research has estimated that the state's cost for Medicaid would increase only 5 to 6 percent over the amount it would pay if the program were not expanded. The federal government now pays more than 70 percent of the program's cost in Kentucky.

More background on Mediaid in Kentucky is available from a PowerPoint presentation that Deputy Medicaid Commissioner Lisa Lee gave yesterday at a meeting sponsored by the Foundation for a Healthy Kentucky and the Kentucky Rural Health Association. It can be downloaded here.

Medicaid expansion would have 'a big health impact,' and critical-access hospitals need to change, rural-health expert says

Expansion of the Medicaid program under federal health-care reform would have a major beneficial impact on the health of Kentucky, a doctor who ran the state and national rural-health agencies told a rural-health meeting in Louisville Tuesday.

"Medicaid expansion has a big health impact," Dr. Wayne Myers, left, told those at "Doing Care Differently in Rural Kentucky," a seminar sponsored by the Foundation for a Healthy Kentucky and the Kentucky Rural Health Association in Louisville, just before the opening of the National Rural Health Association's three-day conference in the city.

Myers said that in the three states that expanded Medicaid eligibility since 2000, one life was saved for every 176  people added to the program, according to a study by the Harvard University School of Public Health, published in the New England Journal of Medicine. If that figure were extrapolated to the entire nation, the number of lives saved would be greater than if breast, prostate and stomach cancer were eliminated, Myers said.

Skeptics argue that Kentucky can't afford the estimated 6.3 percent annual cost increase for expanding Medicaid eligibility up to 138 percent of the federal poverty level, but Myers said, "It would be nice to shift that argument from dollars to health impact." He said that if the three cancers were curable with a certain amount of money, and you argued that the nation should not spend it because of the cost, "You'd have an uphill argument."


Myers also said Eastern Kentucky would be an ideal place for Medicaid and Medicare to start rewarding small, rural hospitals for increasing their role in health promotion and disease prevention.

The federal designation of "critical access hospital" has kept open many rural hospitals, which get greater Medicare and Medicaid reimbursements in return for limiting beds, procedures and patient stays, but President Obama's proposed budget calls for revoking the CAH status of some hospitals, and rural political clout has declined with the rural share of the nation's population, Myers noted.

"The old models aren't working too well," Myers argued, saying "What people don't realize is that [critical-access] hospitals get three-fourths of their money from the outpatient department" and have relatively few traditional admissions. He said half of them have fewer than four acute-care patients per day, and fewer than two patients who are recuperating or getting skilled-nursing care.

Then he displayed maps showing that life expectancies of rural Americans are not keeping pace with the rest of the country, and in some areas, including Eastern Kentucky, are declining. "That's really scary," he said.

Myers said those trends mean that CAHs should add health promotion and disease prevention to their job description, and Medicare and Medicaid -- which provide 85 percent of their revenue -- should pay them for performing that function.

He said hospitals have space, expertise and equipment to serve as exercise and medical-education centers, while most rural health departments are "overwhelmed" with a wide array of duties.

The federal payments for disease prevention and health promotion could be limited to hospitals in counties that have a certain percentage of their population on government-subsidized insurance, he said.

"If it makes sense anywhere, does it not make sense in Kentucky?" Myers asked, reiterating the question to focus on the state's Fifth Congressional District, which he said has the nation's lowest life expectancy. When a questioner mentioned the district's congressman, House Appropriations Committee Chairman Hal Rogers, Myers suggested the program could be named for the Somerset Republican.

Other speakers at the seminar called for new approaches in rural health, despite obstacles.

"Change is not easy. . . . Almost all federal policy tends to shortchange rural, at least initially," said Craig Blakely, dean of the University of Louisville's School of Public Health and Information Sciences.

He said two important targets for prevention activities in rural America are smoking and obesity, which he said is exacerbated by high soft-drink consumption. Soft drinks are a $57-billion-a-year industry, jhe said, "so there's a lot of pushback we're going to be facing if we want to take that on."

Blakely added that much of rural America is poor, and that is associated with poor health, so rural health providers also need to focus on education and employment opportunities for their communities.

Beshear says he will decide in four to five weeks, or July 1 at the latest, whether or not to expand Medicaid

By Al Cross
Kentucky Health News
This story has been updated.

Gov. Steve Beshear said Monday that he will decide within the next four to five weeks, or maybe by July 1, whether to expand the Medicaid program under federal health-care reform.

Beshear, who has said he would expand Medicaid if the state can afford it, told reporters that he is considering other factors, which he did not name. He said his administration has not calculated the cost of expansion, which the state would not pay immediately.

The federal government pays about 71 percent of Medicaid's cost in Kentucky, and would pay the full cost of covering those newly eligible in 2014-16. The state would have to pay 3 percent in 2017, rising to 10 percent by 2020.

About 830,000 Kentuckians are covered by Medicaid, and at least 400,000 more could be added if Beshear expanded it to include households earning up to 138 percent of the federal poverty level, as required by the reform law.

Another possibility is that Beshear would seek approval from the federal government to use federal money to subsidize purchase of private health insurance by the poor, which has been approved in Arkansas but not in Tennessee.

The governor's office, asked if the administration was considering that option and what other factors Beshear is considering, has not responded had this response: "The governor is considering multiple issues as he determines whether Kentucky will expand Medicaid eligibility.  Along with affordability for the state, he is also looking at potential economic impact through jobs and investment created by possible expansion, as well anticipated changes in health outcomes for newly-eligible Kentuckians."

That is also the case with There has still been no response from Humana Inc., which does much of its business through government-financed health plans. The Louisville-based insurance company was asked if it has had discussions with the Beshear administration about the idea of a Medicaid expansion that would use federal money to buy, or subsidize the purchase of, private health insurance.

"Beshear said Monday that he is getting a lot of pressure from the medical field – particularly hospitals – to green-light the expansion," Beth Musgrave of the Lexington Herald-Leader writes. "Hospitals will lose additional money they receive through Medicaid on Jan. 1 as part of the Affordable Care Act. Hospitals in Ohio and other states have also put pressure on state governments to expand Medicaid rolls."

Beshear said, “I think they look at the expansion as a means to at least replace some of that (money) that they are going to lose.”

Many Republicans have opposed expansion, "saying that the state could not afford it," Musgrave writes. "The Republican-led state Senate passed a bill during the legislative session that would have required that the two-term Democratic governor get legislative approval before expanding the health care program. But the measure died in the Democratic-controlled House. Beshear could expand the program via executive order."

Beshear said today, “We have a very large uninsured population and we have a very unhealthy population. Anything that we can do — that we can afford — to make our population more healthy, I”m certainly in favor of doing.” He added, “We are looking long-term as well as short-term from a financial standpoint to see if it makes sense for us.”

While he said he would act within four to five weeks, Beshear gave himself some wiggle room, saying also that he would make the decision by July 1, the beginning of the state's fiscal year. (Read more)

If Republican governors are agreeing to expand Medicaid after lobbying by hospitals, can Beshear be far behind?

By Al Cross
Kentucky Health News

Florida Gov. Rick Scott's surprising announcement that he would use federal health-care reform money to expand the Medicaid program to households earning up to 138 percent of the poverty level "means the dominoes are falling," says Ron Pollack, executive director of Families USA, a consumer group that lobbied for the law. And another domino seems likely to be Democratic Kentucky Gov. Steve Beshear, without involvement by the state legislature.

Beshear has said he will expand Medicaid if Kentucky can afford it, and has mentioned that the state can reserve the right to pull out of the deal in 2017, when it must start paying a small but increasing share of the cost, reaching 10 percent in 2020. Scott used the same qualification.

Pollack told The New York Times that the message sent by seven Republican governors' acceptance of the deal is  “Even though I may not have supported and even strongly opposed the Affordable Care Act, it would be harmful to the citizens of my state if I didn’t opt into taking these very substantial federal dollars to help people who truly need it.” The GOP governors (of states outlined in Times map below) have said they will expand the program partly to protect rural hospitals and the poor.

"The change of heart for some Republican governors has come after vigorous lobbying by health industry players, particularly hospitals," the Times notes. "Hospital associations around the country signed off on Medicaid cuts under the health care law on the assumption that their losses would be more than offset by new paying customers, including many insured by Medicaid. . . . Every few days, state hospital associations and advocates for poor people issue reports asserting that the economic benefits of expanding Medicaid would outweigh the costs." (Read more)

Kentucky Hospital Association President Michael Rust said the trade group is for "universal coverage" by whatever means but is not lobbying Beshear for Medicaid expansion. "We assume he is" going to expand it, Rust said in an interview today. He said the association has not taken a position on bills that would require legislative approval of expansion and the health-insurance exchange being set up under the reform law. The legislation, Senate Bill 39 and SB40, passed the Republican-controlled Senate on party-line votes today, and are expected to die in the Democratic-majority House.

Senate Majority Floor Leader Damon Thayer said the bills were aimed at reining in "big daddy government." Here's a video from cn|2:

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

Fiscal-cliff deal revives program that helps rural hospitals dependent on Medicare; 200 in nation, 10 in Kentucky

Even though most of the hospital industry wasn't happy with the fiscal-cliff deal that will only pay half the $30 billion needed to avoid a 27 percent Medicare fee cut for doctors, the deal gave about 200 rural hospitals, including 10 in Kentucky, reason to celebrate. It extends a program that pays hospitals up to several millions of dollars a year because they have fewer than 100 beds, are located in rural areas and have a high percentage of Medicare patients, Phil Galewitz of Kaiser Health News reports.

The Medicare Dependent Hospital Program was created in 1990 and is one of several payment programs designed to help small, rural hospitals deal with financial challenges that larger hospitals don't face. The program is based on the idea that "some rural hospitals have such a high percentage of Medicare patients they are unable to get enough money from higher paying privately insured patients to make up for the lower government reimbursements," health lawyer Eric Zimmerman told Galewitz.

The program has come under scrutiny. Congress allowed it to expire in September 2012, but two senators from New York and Iowa made sure $100 million for the program made it into the budget deal. The Medicare Payment Advisory Commission said hospitals in the program will receive about 25 percent higher reimbursements as a result of the funding. (Read more)

The Kentucky hospitals in the program are Clinton County Hospital, Fleming County Hospital, Harrison Memorial Hospital, Jewish Hospital Shelbyville, Logan Memorial Hospital, Monroe County Medical Center, Parkway Regional Hospital in Fulton, Rockcastle Regional Hospital, Taylor Regional Hospital and Westlake Regional Hospital in Columbia. The Appalachian Regional Hospital in Williamson, W.Va., is also considered a Kentucky hospital in the program.

Lame-duck Congress could cut funding for critical access hospitals; more than two dozen in Kentucky

Critical access hospitals, which in most states are rural facilities with fewer than 25 beds, may be under attack in the lame-duck session of Congress, former national rural-health director Wayne Myers writes for the Daily Yonder. President Obama's "budget proposes to revoke CAH status and special payments for any such hospital within 10 miles of another hospital, and to cut the extra 1 percent payment for all of the critical access hospitals," Myers writes. (Census Bureau map of CAH locations)

This would "have enormous consequences," Myers writes. "Of the hospitals that lose CAH designation probably most will close or merge with another hospital. I've seen no estimates of numbers. There are more than a few congressional budget hawks in both parties who would like to eliminate the special payments to Critical Access Hospitals entirely. If these small hospitals dodge the bullet during the lame duck session, they'll continue to be targets in the next Congress. If they are successful in reducing payments to CAHs, the net effect will be to move health care capacity and jobs from smaller to larger towns."

The issue is complex. Rural areas have less political clout than ever, because of declining population, and many rural people use urban hospitals over CAHs, even for ordinary care. "Those who do use CAHs say their experience there is just as good as that in urban hospitals, even if the quality of care isn't as good as in larger facilities," Myers writes. "Elderly patients stay at CAHs because they know the nurses and doctors and their families live close by."

Issues for CAHs arise out of how Medicare payments are made to them, Myers writes. "A long list of arcane, special funding arrangements has accumulated to try to fit small rural hospitals into a Medicare payment system designed for large city hospitals." The largest program is the "Disproportionate Share Program," or DISH, which gives $15 billion a year to states to hand out to CAHs. The program is being phased out between 2014 and 2020, along with several other programs, as part of the Patient Protection and Affordable Care Act. (Read more)