Employers welcome delay in coverage mandate, but individual mandate remains and many uninsured people are unaware of it

By Molly Burchett

Kentucky Health News

The Obama administration's decision to delay, for a year, the health-reform law's mandate that employers of more than 50 workers offer them coverage could jeopardize the success of the law -- which already faced several challenges.

The linchpin holding the wheels of "Obamacare" together is an individual mandate, which remains in effect. Millions of people must sign up for insurance coverage -- especially those who are healthy. About 50 million, including 640,000 Kentuckians, who haven't bought or been able to buy health insurance will have to do so or pay a tax penalty, unless they qualify for the expanded Medicaid program.

The delay in the employer mandate could reduce the number of uninsured people who will use state-based insurance exchanges to shop for insurance coverage starting Oct. 1, said Sara Rosenbaum, a professor of health law and policy at George Washington University and an advocate of the law. A White House spokeswoman disputed that, but Obama and his allies face four other broad challenges in implementing the law, as outlined in a recent Politico story by Jason Millman and Joanne Kenen:

1. Uninsured don't know they must get health coverage or pay a tax penalty

Many people know about Obamacare, but a large percentage of the uninsured do not know that they will soon be required to buy coverage, according to the most recent Gallup poll:

2. Middle-class and low-income Americans don't know about subsidies

Another part of the Obamacare message that hasn't yet gotten through to millions of Americans, at least those who need to know, is that the law offers subsidies for coverage, based on income. The challenge is that this message must get to a hard-to-reach population without inflating the law's benefits, Millman and Kenan write. And, many of those who qualify for Medicaid or subsidized coverage are low-income, may not speak English well, or may know little about health insurance.

On top of these obstacles, there can't be a consistent, nationwide message because the coverage criteria is different for states like Kentucky that aren't using a federal health insurance exchange. Kentuckians can visit the exchange website, Kynect, to see if they qualify for special discounts or tax credits to help cover the costs of coverage. For example, the website indicates that a family of four making $48,000 a year will get an estimated $252-per-month tax credit for buying insurance. For a PDF fact sheet about payment assistance, click here.

3. Appealing to young invincibles and businesses

For the new system to work, it is critical that young, healthy people buy insurance to cover the cost of care for older and sicker individuals and keep overall premium costs down. Many young people don't know what an insurance premium or co-payment is, and many don't think they need health coverage. Still, Obama administration officials have said they’re hoping 7 million people sign up for private insurance through exchanges in the first year, including 2.7 million young adults.

The delay in the employer mandate came as a relief to many employers who say it will put their businesses at the brink of survival. But the requirement has only been delayed to 2015, not repealed. Before the delay, some companies with payrolls slightly above or below the 50-employee threshold said they would cut or keep their number of full-time workers below that figure to avoid providing coverage.

Many businesses with 50 or fewer employees don't know they won't be penalized for not offering health coverage and that they can get tax credits for providing it. Kentucky businesses can use Kynect to buy coverage if they have 50 or fewer employees. Significant tax credits may be available through the site for businesses that have fewer than 25 employees with an average annual salary under $50,000; the employer must pay at least 50 percent of the premium for each employee. See the chart below or click here for more details.

4. Threats to public messaging campaigns from the opposition

While the success of Obamacare may depend upon public awareness and outreach efforts, the efforts of those opposing it create additional challenges for supporters. Many Republicans used the delay announcement to advance the cause of overall repeal or delay of the individual mandate. House Speaker John Boehner said, “I hope the administration recognizes the need to release American families from the mandates of this law as well. This is a clear acknowledgment that the law is unworkable.”

Senate Republican Leader Mitch McConnell of Kentucky said, “The White House seems to slowly be admitting what Americans already know, and what I hear consistently in my travels around Kentucky regarding the regulatory burden on employers.”

On the other hand, former White House health policy adviser Ezekiel Emanuel said on MSNBC’s "Morning Joe" that the delay of the employer mandate will affect a relatively small number of companies and is no big deal. The provision only applies to about 200,000 employers who have 50 or more employees working full-time (which the law defines as 30 hours or more a week), he said, and “94 percent already offer health insurance.”

Summer lunch programs promote healthy eating habits for students, their families and the entire community

Carol Greenwell, who runs the summer lunch
program for Bardstown City Schools, hands
Brennen Maddox a carton of fat-free milk after
he picks up lunch. (Photo by Jennifer Corbett)

Both school districts in Nelson County are whipping up a magic solution to childhood obesity, using a key ingredient to promoting healthy eating habits in children: their parents.  The summer school lunch programs not only serve healthy foods while providing education about them, but also establish partnerships with parents in the community to do the same.

School officials say the summer lunch programs are a way to instill healthy eating habits at an early age, in collaboration with parents.  If parents don’t encourage healthy eating habits early on, children's health could suffer long-term and they are at greater risk for developing chronic diseases like heart disease and type two diabetes, writes Jennifer Corbett of The Kentucky Standard.

A recent Kids Count report says that in 2010, 17.4 percent of Nelson County children were considered obese, up by one-sixth since 2006, when the figure was 14.9 percent, notes Corbett.

Experts say that in order to encourage kids to take healthy steps to lose or maintain weight, or improve health, the whole family should be involved. For example, parents should think of fun, physical activities the whole family can do together, such as walking the dog or hiking.

“The best thing parents can do is be a good role model,” Jessica Bickett, a registered dietitian with the Lincoln Trail District Health Department, told Corbett. “If Mom and Dad walk around with a Mountain Dew in their hand all day, well guess what? The child will want to do it as well. If Mom says, ‘Go ride your bike’ while she sits on the couch watching TV, that doesn’t go too well.”

Schools also play a vital role in establishing a healthy lifestyle for students, says the Centers for Disease Control and Prevention., and Nelson County School Supt. Anthony Orr agrees. “We know nutrition is a really important part of growing up,” he told Corbett, adding that the summer lunch program “is a really good opportunity for the schools to serve the community.”

As part of the summer school lunch program, both Bardstown and Nelson County schools serve free breakfast and lunch to students, and adults can pay a small amount to eat, too. Orr is working to get the program into more schools because serving kids and their families introduces healthier choices to the students. This month, Bardstown established a district coordinated school health council focused on providing opportunities for all students to be active and to ensure that school food meets nutritional guidelines. These initiatives could serve as a model for a state that suffers from high childhood obesity and low health rankings. (Read more)

Family physicians group objects to cuts to primary-care physician training programs; cites doctor shortage, which is worse in Ky.

Facing an already-existing shortage of primary care in the country and state, the American Academy of Family Physicians sent a letter to U.S. Rep. Harold Rogers, R-Ky., chairman of the House Appropriations Committee, saying the committee's 2014 funding allocations could damage the nation's primary-care infrastructure by cutting primary-care physician training and research programs.

In the June 18 letter, AAFP Board Chair Glen Stream wrote, "We are concerned that the House-proposed allocation will be inadequate to make the necessary investment in vital primary care research and physician workforce training." The proposed allocation would reduce funding for the only federal program that provides funds specifically to academic departments and programs that increase the number of primary-care health professionals, says an AAFP release.

There are not enough primary-care physicians being trained to meet the demand for services, and a recent study shows only a fourth of newly educated doctors actually go into this field. Even worse for Kentucky, which faces a critical doctor shortage amid Medicaid expansion, less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services. The study's lead author wrote, "If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse."

How can Kentucky meet the critical demand for new doctors when Congress has proposed to make additional cuts to training programs?  Kentucky needed to increase its number of doctors and other medical professionals even before the state decided expand Medicaid, says a recent review by Deloitte Consulting.  The review found that the state needs 3,790 additional physicians, including primary-care doctors and specialists, and the doctor shortage is worse among rural communities.

10 years ago, Lexington's smoking ban started creating a healthier city and a movement among others in Kentucky

A decade ago, Lexington took a bold step by enacted the state's first public smoking ban, in a city that once proudly touted its status as the "World's largest burley tobacco market." As smoke-free supporters and Lexington residents celebrate the ordinance's 10th anniversary Monday, a recent editorial in the Lexington Herald-Leader highlights the dramatic benefits that have followed this historic step.

After the smoking ban took effect in April 2004, the city had 22 percent fewer emergency room visits for asthma in the next 32 months, and the Fayette County smoking rate has dropped from 26 percent to 17.5 percent, the editorial notes. These positive changes have yielded health-care savings of $21 million a year, says the University of Kentucky's Tobacco Policy Research Program.

"There is nothing quite as cost effective as smoke-free policies," the editorial quotes Ellen Hahn, a UK nursing professor and director of the Kentucky Center for Smoke-Free Policy, as saying. "We predict a 32 percent decline in smoking rates if Kentucky were to go smoke-free. That would save billions in health care costs and reduce premature death and suffering from the chronic diseases that plague Kentucky."

The editorial also says Lexington led the way for Louisville and 20 other municipalities to protect citizens from secondhand smoke; a third of the state's population now lives in a smoke-free environment, and many of the initial fears about a smoking ban are now extinguished.

Kentuckians feared economic harm, the shunning of Lexington restaurants and bars and suffering tourism or downtown attraction, but the opposite predictions came true, says the editorial. The scene in downtown Lexington is "far richer than 10 years ago... It once was an article of faith that tobacco would always be king in Kentucky, yet tobacco declined and agriculture has thrived."

Judge refuses to stop Kentucky Spirit from leaving the state, saying health cabinet has had plenty of time to prepare

A Kentucky Court of Appeals judge refused on Monday to stop Medicaid managed-care firm Kentucky Spirit from leaving the state on Friday, July 5. Chief Court of Appeals Judge Glenn E. Acree denied the Cabinet for Health and Family Services' emergency motion to require the company to stay through August.

Read more here: http://www.kentucky.com/2013/07/01/2700062/court-refuses-to-block-kentucky.html#storylink=cpy

Last week, a Franklin Circuit Court judge said  the state can't require Kentucky Spirit to keep serving Medicaid beneficiaries two months beyond its July 5 exit date. When filing the emergency motion last week, Cabinet officials said that if Kentucky Spirit leaves the state without a two-month transition plan, it will “jeopardize the health” of 125,000 people.

However, Acree said the cabinet has had plenty of time to prepare for the company's departure, reports Beth Musgrave of the Lexington Herald-Leader. Furthermore, Kentucky Spirit said the state has refused to work with it to ensure an “effective” transition, and Franklin Circuit Judge Thomas Wingate said last week that the state has “been repeatedly cautioned by this Court to prepare for this contingency, and a lack of preparation at this junction does not warrant a grant of the extraordinary remedy of injunctive relief” requested by the state.

The cabinet argues that Kentucky Spirit did not communicate its intentions to leave, despite Wingate's May 31 ruling until the cabinet took Kentucky Spirit back to court earlier this month, reports Musgrave. However, Kentucky Spirit said in October 2012 that it was pulling out of Kentucky's managed-care system because it was losing too much money covering the 125,000 Medicaid enrollees contracted to the company.

So what will happen now? The cabinet has argued that the two other Medicaid managed care companies — Coventry Cares and WellCare — would take on the Kentucky Spirit beneficiaries and letters have been sent to Kentucky Spirit's clients and to health care providers.  A May ruling said Kentucky Spirit could face fines if it terminates its three-year contract before expiration in July 2014; Kentucky Spirit's appeal in that case is still pending. 

Eastern Kentucky reluctant to accept HPV vaccination that helps prevent cervical, mouth and throat cancers

By Molly Burchett
Kentucky Health News

New research indicates that HPV, the sexually transmitted human papilloma virus, is now the leading cause of mouth and throat cancers in the United States, ranking above both alcohol use and smoking. This problem has a solution, since some cancers caused by HPV can be easily prevented by vaccination, but many Kentucky women are stiff-arming the solution as researchers found they "literally could not give the vaccine away to young women" in Eastern Kentucky.

In Kentucky, vaccination rates remain low, particularly in the east, where the percentage of women who die from cervical cancer is significantly greater than in the rest of state or the nation, notes Tom Collins in a recent Lexington Herald-Leader article. Collins is the associate director of the University of Kentucky's Rural Cancer Prevention Center, which initiated a project to explore the acceptance of the HPV vaccine.

Read more here: http://www.kentucky.com/2013/06/30/2698240/rural-kentucky-slow-to-embrace.html#storylink=cpy

Since 2000, scientists have known that certain strains of HPV are responsible for nearly all cervical cancer in women, and newer studies link HPV to head and neck cancer for many men too. This year, about 14,000 people in the United States will be diagnosed with oropharyngeal cancer, most of them will be young, between 40 and 50 years old and 75 percent will be male, says a Newswise article. A decade ago, patients with head and neck cancer were smokers or drinkers, but now 80 percent of the cancers are caused by HPV.

About half of all Americans will become infected with HPV at least once their lifetime and it's difficult to recognize the symptoms of the virus, making vaccination even more important. The federal Centers for Disease Control and Prevention now recommends that boys and girls both be vaccinated against HPV between the ages of 11 and 12 and up to the age of 26, says Collins.

Collins writes that Eastern Kentucky is slow to accept the vaccine, even when promoted at community events such as hog roasts. Despite the initial reluctance, "Researchers at the center hope that if a community is engaged in the process and allowed to direct the delivery of the necessary change, outcomes can be achieved that will lead to a healthier population," he Collins.

And, there's still hope. The national prevalence of infection in young women has declined by more than half since the introduction of the HPV vaccine, despite low vaccine usage, says recent findings by the CDC. This decline occurred even though only a third of eligible patients received the vaccine, so imagine the benefits afforded to Kentuckians with efforts to improve vaccination acceptance and usage.

Kentucky will soon require simple screening at birth to detect silent killers of newborns

A new state law taking effect in January will require all babies born in Kentucky to be screened for critical congenital heart disease, which is often a silent killer of newborns who appear to be healthy and who are discharged from the hospital with the unrecognizable disease.

Since Indiana became the first state in the nation to get such mandatory screening signed into law in May 2011, more than 20 states have passed legislation requiring a non-invasive, inexpensive screening test called pulse oximetry at birth, reports Laura Ungar of The Courier-Journal. The test can detect this life-threatening disease and allow health care providers to act quickly to save the baby's life.

Don Shieman, Kentucky state director of the March of Dimes, who helped lobby for the law with the state legislature, said about 65 infants are born with CCHD in Kentucky each year. “If we can detect the problem soon enough, we can save lives,” Shieman told Ungar. State Sen. Dennis Parrett, an Elizabethtown Democrat who helped sponsor the state’s new law, said this requirement is a simple solution to a deadly problem he know something about.

“My wife and I have some experience with this,” Parrett told Ungar. “Our younger daughter was born with a severe heart defect” called tricuspid atresia, and underwent surgery at Kosair Childen's Hospital and her heart is doing fine, Parrett told Ungar. “There’s a lot of infants whose heart defects are not caught,” Parrett said. “What we wanted to do is make it a part of normal infant screening.”

Each test costs about $4, so Parrett said there’s no real fiscal impact to adding pulse oximetry to the list or required screenings for newborns, says Ungar. In general, hospitals already have the equipment for the test, many of which are already doing the test.

The legislation could lead to success stories similar to that of Shooter Bratcher of Caneyville, right, who was treated for infection and underwent surgery for CCHD recently at Kosair. Shooter was born full-term and and seemed normal at birth, but about five days after going home, things just didn't seem right, and he kept getting worse. Shooter's parents took him to the ER at their local hospital, Twin Lakes Regional Medical Center in Leitchfield, where doctors didn't pick up on his CCHD, Ungar reports. A day later, he went by ambulance to Kosair, and could have died if his parents didn't notice the little signs of a problem. Unfortunately, such signs sometimes show up at night, when parents are asleep or not paying close attention. Other times, the disease isn't caught quickly enough, leading to serious serious problems such as infections, brain damage, disability or death, Ungar reports.


Pulse oximetry will allow health care providers to detect seven types of CCHD. For more information about the test, the law or to watch a video in which Shooter's parents share their story, click here.