Politicians, economists and journalists debate the reasons for, and the impact of, proposed sale of Humana to Aetna

By Al Cross
Kentucky Health News

The purchase of Louisville-based Humana Inc. by fellow health-insurance giant Aetna Inc. for $37 billion still needs approval from federal anti-trust officials, partly because of the possibility that the merger will reduce competition and increase premiums.

Some other public officials, the elected kind, wasted no time weighing in on the sale. And, since it deals with health insurance, it may come as no surprise that their statements followed partisan lines, reflecting their views of the Patient Protection and Affordable Care Act.

Wall Street Journal graphic

Even before the deal was announced, Senate Majority Leader Mitch McConnell, R-Ky., said Thursday, "You’ve seen the rumors about Humana being gobbled up by someone who’s even bigger. This kind of government takeover of the private health-insurance market – think of it this way: what Obamacare has basically done is taken the private health insurance market and turned it almost into a regulated utility."

In a press release Friday, McConnell said, "This morning’s announcement, as I predicted during the debate five years ago, is the inevitable result of Obamacare’s push toward consolidation as doctors, hospitals, and insurers merge in response to an ever-growing government."

U.S. Rep. John Yarmuth, D-Louisville, said consolidation in the health-care industry has been going on for decades, "and it is appropriate for the Department of Justice to scrutinize the pending merger to ensure it does not reduce competition, and therefore, consumers' options."

Louisville Mayor Greg Fischer, a Democrat who ran in the primary for McConnell's seat in 2008, said he was "a little surprised by the political nature" of the senator's statement. Fischer and Democratic Gov. Steve Beshear were generally upbeat about the merger. "I am cautiously optimistic that this merger will be a net positive for Louisville and the commonwealth," Beshear said.

Humana has 12,500 employees and 1,500 contractors in the Louisville area. Fischer said, "I think it's very fair to speculate that it will lead to more jobs," and Bruce Broussard, president and CEO of Humana, said, "I think Louisville will be a net beneficiary as a result of this transaction."

However, University of Louisville finance professor David Dubofsky "said it may not turn out so well for the Louisville and Humana employees after all," The Courier-Journal reports, quoting him: "When two companies in the same industry merge, and the acquirer is paying a premium, you have to generate cost savings," partly by reducing employment among workers with similar jobs.

There is a connection between the merger of health-care providers, such as the creation of Kentucky One Health by several hospital groups, and the merger of insurance companies. "Many experts have said that the provider consolidation can drive higher rates—and that more-powerful insurers might have a better chance of countering them and striking pacts for new forms of payment that incentivize efficiency," Anna Wilde Matthews and Christopher Weaver write for The Wall Street Journal.

But they also note, "Research suggests that having fewer insurers leads to higher premiums, said Leemore S. Dafny, a former Federal Trade Commission official who is a professor at Northwestern University’s Kellogg School of Management.

Aetna with Humana would dominate the Medicare Advantage market in some states, with 90 percent of it in Kansas, notes Drew Altman, president of the Kaiser Family Foundation. "Of course, regulators could insist that companies take steps to maintain more competitive markets."

The Journal reports that it analyzed a Medicare database and found, "An Aetna-Humana tie-up would increase by about 180 the number of U.S. counties where at least 75 percent of customers for Medicare Advantage plans are in the hands of a single insurer." Most of those counties are in the South and Midwest. Using another federal database, it found that "In eight states, an Aetna-Humana merger would remove a competitor from the exchanges where individuals can buy coverage under the Affordable Care Act."

The prospect that jobs might be lost in Louisville doesn't mean that the ACA has put financial pressure on Aetna or Humana, Dan Diamond writes for Forbes magazine: "There’s limited evidence that the biggest players are struggling. While the ACA capped insurers’ ability to take profits, industry analysts have been fairly bullish on the sector. . . . And as I wrote earlier this week, the ACA appears to have only helped major insurers, by driving millions of new customers into the market. Aetna and Humana have seen their stock valuations triple in the past five years, since the ACA was signed into law, and the other three major insurers also have seen huge gains."

Diamond also isn't buying the argument, advanced by Aetna officials, that the combined company will be more efficient than the separate ones. "Aetna and Humana already are giant, scaled entities," he notes. "And economists aren’t buying the claim that insurer consolidation will lead to lower costs." As Judy Woodruff noted on "PBS Newshour" Friday, the deal would give the combined company more leverage to negotiate payments to health-care providers.

Health insurers' shares of total Medicare Advantage business
(Kaiser Family Foundation chart)

Diamond says the best case for Aetna's purchase is that it gets the company deeply into the Medicare Advantage business, without having to expend "a great deal of work and time," as Michael Bernstein, a partner at Baird Capital partner who focuses on health care, told Bloomberg News last month. Aetna has only 7 percent of that business, Humana 19 percent -- and about 65 percent of its revenues came from Medicare Advantage plans in 2014, Altman notes. The combined company is expected to get 56 percent of its revenue from government programs.

Diamond says economists see one more possible reason for the merger: "Amid health care’s merger mania, insurers are feeling psychological pressure to make deals of their own." And that does take us back to Obamacare. But the impact on Kentucky has yet to be seen, and so do the reasons.

Republican legislators question cabinet's figures on managed-care payments and cost projections for Medicaid expansion

Audrey Haynes (cn|2 image)

"When Audrey Haynes sat down before the legislature’s Medicaid Oversight and Advisory Committee Wednesday, she expected the data she brought would persuade lawmakers that Kentucky’s expansion of Medicaid has been good for the state," Ronnie Ellis reports for CNHI News Service. "The secretary of the Cabinet for Health and Family Services, which administers the Medicaid program also may have expected her statistics to ease unhappiness with the state’s move to managed care for most Medicaid services."

"It didn’t happen," Ellis writes. "At least she didn’t persuade Republican members who openly questioned the validity of the cabinet’s data, a couple stopping just short of saying the cabinet is making up the numbers" about payments to providers by managed-care organizations, which it says are 99 percent on time. “The numbers do not appear to represent the reality on the ground,” Rep. Richard Benvenuti, R-Lexington, said after the meeting.

Sen. Ralph Alvarado

“I think those are false,” Sen. Ralph Alvarado, R-Winchester, said after the meeting. “I don’t know if they’re lying, but somebody is providing bad information.”

During the meeting, Alvarado read "segments of letters from providers who have not received full reimbursements from managed care organizations," reports Kevin Wheatley of cable channel cn|2's "Pure Politics."

"Haynes referenced a report from CHFS which showed that over 90 percent of Medicaid claims are being paid in a timely manner," reports the blog of the Kentucky Chamber of Commerce. "Sen. Alvarado replied that this statistic does not match what he is hearing from his constituents and medical providers." Haynes addressed the managed-care issue in her PowerPoint presentation, downloadable here.

Rep. David Watkins, D-Henderson, a retired physician and co-chair of the committee, "urged the panel to find ways to improve managed care."

Watkins said the managed-care organizations, which are insurance companies or their subsidiaries, should come before the committee to answer questions. “I’m not totally satisfied that they’re doing quite as good a job as your report here would portray,” he told Haynes. “I think they need to be more accountable. I think they need to be more responsive to the providers who actually are doing work in the field.”

The MCOs will appear before the joint House-Senate committee Aug. 19, Brad Bowman reports for The State Journal in Frankfort. For cn|2's three-minute clip of the discussion between Haynes and Alvarado, via YouTube, click here.

The Republican lawmakers also voiced skepticism, but offered no contrary evidence, about the cost of expanding Medicaid to households with incomes up to 138 percent of the federal poverty level, from the previous limit of 69 percent. Under the Patient Protection and Affordable Care Act, the federal government is paying the entire cost of the expansion until next year, when the state will begin paying a small part, rising to the law's cap of 10 percent in 2020.

Haynes noted projections for Democratic Gov. Steve Beshear's administration that the expansion would add $30.1 billion to the state's economy through 2021, and would pay for itself until then, even after the state starts picking up part of the cost. The numbers were not new; they were part of a study by Deloitte Consulting and the University of Louisville that Beshear released in February.

Republicans focused on the prediction that the expansion would cost the state a net $45 million in 2021. "I know that seems like a way long ways off and some of you may no longer even be in the position to deal with it, but some of us probably will and the taxpayers will," said Alvarado, a physician.

Haynes "stated that she believed with the financial boost to the economy through jobs, the costs will be offset," the blog of the Kentucky Chamber of Commerce reports.

“Now that we’re seeing the lowest unemployment that we’ve seen in our state in quite a number of years, I’m sure each of you are amazed at how that we’ve had all 120 counties in our state where the unemployment rate has gone down,” Haynes said. “As this state continues to generate revenue and hopefully, as is planned, this is a bridge program for people who basically are hard-working people, but their employer does not provide insurance or they have children and therefore that qualifies them from an income basis for Medicaid.”

Bevin says he will end all Obamacare programs in Ky., including Medicaid expansion that has added more than 400,000 to rolls

Matt Bevin, the Republican nominee for governor, has made clear that if elected he would end the Medicaid expansion that has provided free health coverage for more than 400,000 poor Kentuckians.

During his primary campaign, Bevin never made that quite plain, saying he would close the state's health-insurance exchange, Kynect, because it would cost "hundreds of millions of dollars." Kynect is paid for by insurance companies, so Bevin was alluding to to the state's projected cost of expanding Medicaid, which enrolls through Kynect.

The Washington-based publication Politico reported on June 10, after interviewing Bevin, that he would not only close Kynect but roll back the Medicaid expansion: “You may or may not have access to Medicaid going forward,” he said. “People are not on it for extended periods of time. It’s not meant to be a lifestyle. It really isn’t. The point of it is to provide for those who truly have need.”

Democratic nominee and Attorney General Jack Conway, with Gov.
Steve Beshear; GOP nominee Matt Bevin (AP photos via Politico)

Gov. Steve Beshear "is furious" about Bevin's plan, Politico reported. “I am not going to allow someone to become governor of this state who wants to take us back to the 19th century,” the governor said in a telephone interview. “For a serious candidate for governor to be advocating a simple repeal of the whole program without offering any kind of alternative which will continue health care for these people is irresponsible.”

Beshear expanded the eligibility rules for Medicaid as part of implementing the Patient Protection and Affordable Care Act, raising the income limit to the law's required 138 percent of the federal poverty level, from the state's previous level of 69 percent.

The federal government is paying the entire cost of the newly eligible Medicaid recipients though next year. In 2017, the state would begin to pay 3 percent, rising to the reform law's cap of 10 percent by 2020. A study by Deloitte Consulting and the Urban Institute at the University of Louisville  — "which Republican critics have rejected as spin," Politico says — has said the expansion more than pays for itself through 2020 by expanding health-care jobs and generating tax revenue.

Jobs are growing as projected by the study, according to the Cabinet for Health and Family Services, which handles Medicaid.

Cabinet spokeswomnan Jill Midkiff said the study estimated that 32,000 jobs would be created through 2015 as a result of the expansion. "U of L projected this growth would primarily be in the areas of retail trade, finance and insurance, administrative services, health and social services, accommodations and food services and other services," Midkiff said. "These sectors were estimated to account for more than 28,000 of the 32,000 jobs created." She said the latest Bureau of Labor Statistics figures show that "these sectors have grown by more than 29,000 jobs from 2013 until April 2015. Therefore, the most recent BLS numbers indicate that UofL’s estimates are on target to meet projections."

Politico says a Bevin victory could "blot an Obamacare bright spot," since Kynect has "worked virtually glitch-free." Through April, 106,000 Kentuckians had obtained tax-subsidized, private insurance coverage through Kynect, which is also the portal for enrolling in Medicaid.

Bevin says he would move those people to the federal exchange, which has been marred by technological issues and charges insurance companies much more to use it than Kynect does. But that plan would not work if the U.S. Supreme Court rules this month that the tax subsidies are not legally available through the federal exchange.

"That doesn’t worry Bevin," Politico reports, quoting him: “You’re worrying about a hypothesis. Let’s let the Supreme Court rule.”

And what about the new Medicaid recipients who would lose their benefits if Bevin wins? He "insists that Obamacare is coverage in name only — that Kentuckians still lack access to high-quality health care, partly because Medicaid pays doctors such low rates, partly because he says too many people rely on emergency rooms," Politico reports, quoting him: “Just having health insurance doesn’t mean you’re going to get health care.”

Attorney General Jack Conway, the Democratic nominee, declined Politico's request for an interview. Campaign spokesman Daniel Kemp said, “Jack wants to make sure that the hundreds of thousands of Kentuckians who now have health insurance through Kynect, especially kids, keep their health insurance — not play politics or push an ideology that’s out of touch with Kentucky’s values.”

Politico observes, "Conway is in the tricky spot of embracing Kynect while trying to keep his distance from Obama and Obamacare, a term that still generates ire among Kentucky residents. A September 2014 Marist [College] poll found that 61 percent of registered Kentucky voters had an unfavorable impression of Obamacare. Only 17 percent had negative feelings about Kynect."

Citing costs, Bevin has said he would shut down Kynect; actually, insurance companies pay for it; Medicaid is another matter

By Molly Burchett and Al Cross
Kentucky Health News

The governor's race between Democrat Jack Conway and Republican Matt Bevin will spotlight the Patient Protection and Affordable Care Act, an issue that affects all Kentuckians at least indirectly.

Conway, in his eighth year as attorney general, says he would have voted for the law. Bevin, who was the most conservative candidate in his primary, has said he would shut down the state's health-insurance exchange, Kynect, that was established under the law, because it will cost the state hundreds of millions of dollars.

Actually, Kynect is paid for by insurance companies that sell policies in Kentucky. Bevin appears to be referring to the projected cost of expanding Medicaid, another Obamacare-related move that Democratic Gov. Steve Beshear made at the same time he created Kynect. It raised the program's income limit to 138 percent of the federal poverty level, from 69 percent.

The federal government is paying the entire cost of the Medicaid expansion for the first three years. In 2017, the state will pay 3 percent, gradually rising to the law's cap of 10 percent in 2020. A study for the state projects that the expansion will pay for itself until 2021 by expanding health-care jobs and generating economic activity and tax revenue.

Bevin has scoffed at those projections. Conway has said the state needs to provide health coverage, but only what it can afford.

As Kentuckians, voters, and consumers of health insurance, you may be asking: What's going on with Obamacare in the state? Are we able to afford it? Who and what should we believe? While the cost of Medicaid expansion is debatable, it's becoming clear that Kynect has avoided the problems plaguing other state-run exchanges.

So far, the Centers for Medicare and Medicaid Services has dispensed more than $4.9 billion in grants to help launch state-run exchanges. Kentucky received $253 million for the initial planning and development phases of Kynect. Now its $28 million annual cost is covered by a fee on insurance companies, state officials say.

Despite federal support and their own revenue sources, many of the 17 state-based exchanges are expecting deficits this year and in the future. Many will continue to rely on leftover federal funds to pay for operations this year, report Darius Tahir and Paul Demko of Modern Healthcare. Hawaii announced this week that it would close its exchange and transfer clients to the federal exchange because of continued funding problems.

Kynect officials say it isn't having such problems because the state has ensured that Kynect is self-supporting through fees on insurance plans.

"The governor committed that the exchange would be self-supporting and would not rely on state General Fund dollars," said Jill Midkiff, spokeswoman for the Cabinet for Health and Family Services. "Kentucky’s sustainability plan employs an existing assessment on insurers that was previously used to fund Kentucky Access, the state’s high-risk pool, which was closed [since] individuals previously enrolled are now eligible to purchase a plan through Kynect."

But to transform Kentucky Access into Kynect, Beshear used executive orders that bypassed the General Assembly, where Republicans control the Senate. They have questioned his use of executive powers but generally have not been critical of Kynect.

The fee on insurers is a 1 percent, broad-based assessment on companies offering plans through the exchange. While insurers don't pass this fee directly to consumers, it almost certainly figures into their calculation of premium calculation and thus is indirectly paid by policyholders. The federal exchange is financed in a similar way, but its fee is 3.5 percent, meaning higher costs for insurers and policyholders.

In most cases, premiums for Kynect policies are reduced by a federal income-tax subsidy that is a key part of Obamacare.

"The vast majority of Kentuckians buying health insurance through Kynect are eligible for some kind of payment assistance or subsidy," Beshear said in commenting on most health-insurance companies recent requests for premium increases. "That cost will vary from family to family, so talking about rate changes in a vacuum isn’t a very effective way to gauge how much those rate fluctuations may affect policyholders or those shopping for insurance."

Bevin says he would move Kynect customers to the federal exchange, but the U.S. Supreme Court could rule this month that the tax subsidies are not supposed to be available through the federal exchange. The plaintiffs in the case cite a passage of the law that opponents say was a drafting error and does not make sense when the law is viewed as a whole.

If the court agrees with the plaintiffs, and Congress doesn't change the law, states using the federal exchanges will see spikes in insurance premiums, and millions of people could be at risk of losing their insurance. Bevin has not said what he would do in case of such a ruling.

Independent Drew Curtis is also running for governor.

Tennessee churches encourage healthier living

Sulphur Wells Church of Christ in Henry County, Tennessee, a few miles away from Paris, Ky., is challenging people to eat and think healthier, Amber Hall reports for Public Radio International.

Bob Palmer, lead pastor at the church, said, "We do draw some hard lines on alcohol and tobacco use and tattoos—we think, 'Oh, you're not taking care of the our temple that God has given you.'" He said the church hasn't looked at the issue holistically. "We've just kind of picked out the things we weren't going to do anyway, and we feel self-righteous about that—that we don't do them."

Then Palmer saw the County Health Rankings, a project by the Robert Wood Johnson Foundation that measures health risks, Hall writes. He said that "when we confirm someone's spiritual health and give them a thumbs up and an A-OK, that's often the end of the rehabilitation process." However, he said if he were outside the church and had only the health indicator numbers to look at, "it might make me run in the opposite direction."

In Tennessee, the Governor's Foundation for Health and Wellness is helping groups such as churches improve health in evangelical hubs through the "Healthier Tennessee" initiative, which is a "wellness program and an online wellness tool that provides faith leaders with tips, ideas and actions to get their members healthier," Molly Sudderth, the director of communications at the foundation, said.

One of the suggestions is called Walk and Worship. "You can walk and pray for those you feel need extra prayers or are going through difficulties . . ." said Barabara Kelly, a public-health educator.

About 150 churches statewide are participating in Healthier Tennessee's "Small Starts" program, but none of the churches in Henry County have joined yet. Palmer said "there could be some stigma tied to healthy living in this largely conservative area," Hall writes.

"Right-wing religious folk have kinda viewed that as 'liberal' thinking," Palmer told him. "But that hasn't been correct, I don't think. At all. Just read through early Genesis, and the very first commission that God gives anyone is to essentially take care of this created world. We don't talk about that very often for some reason—to our detriment, and these numbers reflect that." (Read more)

Washington Post columnist looks at data, talks to experts and concludes Obamacare is working, at less cost than expected

The federal health-reform law "has accomplished its goal of expanding coverage — at a significantly lower cost than expected," columnist Ruth Marcus writes for The Washington Post "after talking to numerous health-care experts and examining the data."

Marcus writes up front, "There is a legitimate ideological debate about whether it is a wise use of federal power to require individuals to obtain health insurance or a wise use of federal resources to spend so much on subsidizing coverage. What’s more puzzling, and more disturbing, is the still-raging division over the real-world effect of the ACA."

She says President Obama "over-promised when he told people that, if they liked their health insurance, they could keep it; by its own terms, the law set new standards for required coverage. Certainly, some individuals, particularly younger and healthier customers, find themselves paying more; again, such winners and losers were an inevitable consequence of the individual mandate and minimum-coverage rules. Meantime, the scariest warnings — of employers rushing to drop coverage and insurance markets ensnared in death spirals of ever-rising premiums — have not come to pass.
Where the law has yet to fully deliver on its promises — and some wonder whether it will — is in the area of cost containment and quality improvement."

Marcus backs up her assessment with facts. For example, "Health-care costs and premiums for employer-sponsored insurance (the way most of us obtain coverage) have been rising at their lowest levels in years. On the exchanges, premium increases during the law’s second year mirrored that modest growth — averaging 2 percent on some mid-range plans and 4 percent on the lowest-cost ones, according to the Kaiser Family Foundation."

Sponsor of local opt-out amendment says smoking-ban bill needs it to pass; sponsor and House leaders don't care for it

By Melissa Patrick
Kentucky Health News

UPDATE: The House didn't vote on this amendment, but Sen. Jimmy Higdon, R-Lebanon, says it or something like it would give the bill a better chance of passing the Republican-controlled Senate.

FRANKFORT, Ky. – Rep. Steve Riggs of Louisville has proposed an amendment to the statewide smoking ban bill that would allow cities and counties to opt out of the ban every two years, saying he wants to improve the bill's chances of becoming law.

Riggs

“This amendment would negate a lot of concern about taking away local rights,” Riggs, a Democrat who supports the ban, said in a press release.

His Floor Amendment 9 to House Bill 145 proposes that local governments be able to opt out of the ban, but would be required to take another vote every two years to prevent the ban from taking effect in their jurisdiction.

Rep. Susan Westrom, five-year sponsor of the ban, first said she welcomes amendments because that is "how we edit our legislation," but still needed to talk to Riggs – and when asked if she thought this amendment was a good idea, she said it "goes against the intent of the bill."

"It is a little bit too late for this amendment," the Lexington Democrat said. "We have made too much progress."

House Speaker Greg Stumbo, who says he supports the bill but has clashed with Westrom about its handling, agreed. "I think if you started from day one with that as the idea," he said, "it might have been more palatable."

Stumbo and Republican Leader Jeff Hoover said the amendment would defeat the bill's purpose.

Hoover

Hoover noted, "Advocates have said for many years that we have to have a state-wide smoking ban because of the health concerns all across Kentucky."

Riggs said in an interview that the legislation hasn't had the votes for the past five years and it is time to do something different.

"If you keep swinging at the ball and missing time after time, you probably ought to change your stance," he said. "And that is what they need to do. They need to make a change to get more votes so it will pass."

Westrom said, "We have the votes." But House leaders told her Friday, Feb. 6, that she would need to have commitments from 55 of the 100 House members before they would bring her bill up for a vote.

"What it really says is, it takes 51 votes to pass, but we want 55 commitments because we can't trust everybody," Hoover said. "It's not about having a cushion; it's about they can't trust their own members when they say they are going to vote for something." He said Democratic leaders "should have the discipline to keep amendments, such as this one, from being filed."

Riggs said as chair of the House Local Government Committee, he is sensitive to the needs of cities and counties, and "If we give those people an option to opt out of it, we might be able to get some votes up here to pass the bill."

He said his amendment would allow the bill's advocates to get 90 to 95 percent of what they want to accomplish. "Most people consider that an A, excellent," he said. "This bill might bring in another 10 votes, because people feel if they have the option to opt out, that is liberty and freedom."

Riggs also said the idea might improve the bill's poor chances for passage in the Senate because some senators showed interest in the approach last year.

This is the right thing to do because they don't have enough votes to pass the bill in the House and the Senate," Riggs said.

He said smoke-free advocates don't want any changes to this bill and have not been willing to compromise for the past five years, and asked, "How much illness can we put at their feet because they won't change their swing?"

James Sharp of the American Cancer Society's lobbying arm, the Cancer Action Network, declined to comment.

Hoover, one of the relatively few Republicans for the bill, said he is mindful of opponents' arguments about personal property rights, but also of the "associated health risk with smoking and second hand smoke and the cost that this state is incurring in treating those folks who have diseases related to smoke and second hand smoke."

He concluded, "When I do the balancing test for me personally, I come down on the side that this is a step in the right direction to reduce health care cost and save lives."

Supporters of statewide smoking ban push for floor votes; opposition in Senate may not be as strong as before

By Melissa Patrick
Kentucky Health News

While the advocates of a statewide smoking ban might have been “preaching to the choir,” as one put it during a legislative committee meeting Wednesday, Dec. 17, they heard a passionate call to go out and persuade their fellow legislators to pass a smoking ban in the 2015 legislative session, or at least give it a vote on the floor of a chamber.

“Go to our members in leadership, both the majority and the minority, and tell them this needs to be a priority this year. We cannot afford to wait any longer,” Rep. Susan Westrom, D-Lexington, longtime sponsor of the House legislation, told the Interim Joint Committee on Health and Welfare. “It will have to begin with us here pressuring them to make sure that this is the number one priority.”

Westrom has sponsored the legislation in the last four sessions. It came close to a floor vote in the full House last year, but has never gotten out of committee in the Senate, even though polling shows that 65 percent of Kentuckians support banning smoking in indoor public places.

Westrom said after the meeting, "There is a large increase in the number of people at the local level who support a statewide smoke-free law. Their soft speech has now turned into a roar."

Rep. Susan Westrom

Westrom said at a recent meeting of the Kentucky Chamber of Commerce, which supports the ban, that her main lobbying adversary is the Kentucky Farm Bureau Federation.

The chamber's support was noted by board member Brent Cooper, president of C-Forward Inc., an information technology firm in Northern Kentucky. He said the law would help improve the health of Kentuckians, which would decrease the cost of insurance for businesses.

“For businesses, that is one of the most compelling reasons to support the smoke-free law,” he said. “Most of my group is a relatively young, relatively healthy group and our insurance premiums went up 30 percent last year and we are facing a huge increase again this year. Why? Because we absorb the state of Kentucky now. We absorb all of the workers in the state of Kentucky and guess what, Kentucky is an unhealthy place," forcing insurance rates up.

Cooper said some legislators who have told their constituents that they would not vote for a smoking ban may now feel differently, but don't know how to tell them they have changed their mind. He said those legislators should educate their constituents.

“Convince them, show them the latest data,” he said. “Show them that blowing toxic fumes in somebodies face impacts their health. Convince them of that. Tell them it is the right thing to do.”

Wayne Meriweather, chief executive officer of Twin Lakes Regional Medical Center in Leitchfield, also representing the Kentucky Hospital Association, gave the legislators an arsenal of facts to educate with:

• 26.5 percent of Kentuckians smoke;
• Kentucky leads the nation in lung cancer and lung cancer deaths;
• Kentucky is the 47th unhealthiest state in the nation;
• Kentucky leads the nation in smoking;
• 7,900 Kentuckians die each year due to active smoking;
• 27 percent of Kentucky's blue collar workers are exposed to second hand smoke at work;
• second hand smoke exposure increases the risk of heart and lung disease by 20 to 30 percent;
• 950 Kentuckians die each year from second-hand smoke.

He then provided facts on how much smoking costs the state of Kentucky:

• $1.92 billion a year for annual health-care expenditures directly as a result of tobacco use;
• $106 million a year in annual health-care expenditures in Kentucky from second hand smoke;
• $487 million a year in state Medicaid expenditures due to tobacco use (this was before the expansion of Medicaid);
• $988 million a year in total taxpayer cost from smoking-related expenses, or $591 per household; and
• $2.3 billion is lost each year because of lower productivity.

Rep. Julie Raque Adams, a Louisville Republican who will be joining the Senate in January and sponsoring the smoking-ban bill there, said it should not be a partisan issue, and "Saving taxpayers' dollars is one of the most conservative things we can do."

Incoming Senate Majority Whip Jimmy Higdon, R-Lebanon said that he supports smoke-free laws on a local level. Sen. Joe Bowen, R-Owensboro, said that while he would likely vote for a statewide smoking ban if it comes to a floor vote, he thinks it should be addressed at a local level.

Senate President Robert Stivers, who has said he does not favor a statewide ban, was less vocal about his opposition in a statement to cn|2's "Pure Politics."

“Sen.-elect Julie Adams has been very upfront concerning her support and sponsorship of a statewide smoking ban and she makes some good points; however, other senators voiced concern that this is a local issue for communities to address and enforce rather than having the state take on another regulatory role at this time,” said Stivers, R-Manchester. “So I see this as one of the issues this session that is going to have to go through the legislative process of discussion and debate and we will see where it goes from there.”

Stivers has previously been more vocal about his opposition to smoking bans, saying they don't offer personal choice and that he believes businesses should have the right to set their own policies.

Westrom said that when she was first asked to sponsor a Smoke-Free Kentucky bill 11 years ago, she also thought that it should be a local decision and declined, but not enough local leaders have stepped up. As of October 2014, 23 Kentucky communities have smoke-free policies that cover all workplaces and enclosed public places, according to the Smoke-Free Kentucky website. This breaks down to 32 percent of Kentuckians covered by strong local smoke-free laws.

With two-thirds of Kentuckians supporting a statewide smoking ban, it is time for statewide leaders to do it, Westrom said.

Some say that public opinion will drive Republicans or leaders of the House's Democratic majority to act this year. House Speaker Greg Stumbo, D-Prestonsburg, reiterated his support for a statewide smoking ban through his spokesman and told Pure Politics that “it may be time for an up-or-down vote” in the House.

The General Assembly's session begins Jan. 6. After a few days devoted to election of leaders, organization of committees and mandatory ethics training, the legislature will recess until early February. The session of 30 legislative days must end by March 31.

Spending bill allows schools that show 'hardship' to vary from requirement to serve 100 percent whole grains

By Melissa Patrick
Kentucky Health News

The massive 2015 spending bill signed by President Obama Dec. 16 includes a provision to help schools struggling with the whole-grain and sodium requirements that are part of the Healthy, Hungry-Free Kids Act. It did not allow, as House Republicans had hoped, schools to opt out of the healthier school meal standards if they lost money on meal programs over a six-month period.

Beginning with the 2014 school year, schools had to serve 100 percent whole grains in their meals and snacks, and also follow the first restrictions on sodium, or salt. The sodium restrictions were scheduled to get progressively stricter over the years, with the next move set for 2017.

The law allows schools that demonstrate the rule is a "hardship" to continue serving 50 percent whole grains. It also says sodium standards cannot be tightened until the "latest scientific research establishes the reduction is beneficial for children," Mary Clare Jalonick reports for The Associated Press.

Some schools say they have had trouble complying with these requirements because many of the affordable whole grain pastas have proven difficult to cook en masse and the whole-grain versions of many foods, like biscuits and tortillas, simply don't taste the same.

On salt, schools say budgeting the allowed amounts among meals, snacks and a la carte items is often a challenge. The issue hit Anderson County schools earlier this year when they couldn't find a low-sodium ketchup; their solution was to not offer ketchup. Parent and student complaints prompted a reversal of that move, but to do that, sodium had to be removed elsewhere in the menu.

The new law won't have much effect on Fayette County Schools, Director of School Nutrition Michelle Coker said in a telephone interview. "Basically, we use 100 percent whole grains in everything," she said. "But there are products, like tortilla shells, that aren't as flavorful and this gives us some flexibility."

Fayette County has transitioned slowly to whole grains over the last five to six years to help students adjust to them, Coker said, and as whole-grain products have become "tastier" the transition has not been an issue.

"Whole grain pasta products have come a long way," Coker said. "Three to four years ago they were dark, but now it is difficult to tell the difference. Kentucky has really good vendors."

Coker, a registered dietitian, welcomed the possible delay in lower salt limits, saying most students are active and involved in sports and shouldn't need such low sodium restrictions. "These kids are growing and need electrolytes," she said.

The School Nutrition Association, a group that represents both school nutrition directors and the food companies that produce foods for schools, wanted even deeper rollbacks than the spending bill included, but said it "strongly supports" the budget-bill language.

Alabama Rep. Robert Aderholt, chairman of the House subcommittee that oversees nutrition issues, said the whole-grains waiver is "the best bill that we are going to get" as long as Democrats are in control the Senate, Jalonick reports.

Republicans will control both houses of Congress next year, so the battle is far from over, and the overall law governing child nutrition policy, including school lunches, expires next year and will require legislation to be renewed, Jalonick notes.

First Lady Michelle Obama, champion for improving school's nutrition and decreasing child obesity, said this summer that she would fight "to the bitter end" to make sure kids have good nutrition in schools.

Medicaid expansion has been more popular than expected, but that raises a question of whether it will really pay for itself

Kentucky officials say the state’s Medicaid expansion under the federal health-reform law has enrolled more residents and created more jobs than expected, but a study will see whether the expansion will pay for itself, as an earlier study and Gov. Steve Beshear predicted.

Eric Friedlander, deputy secretary of the Cabinet for Health and Family Services, reported both a larger-than-expected Medicaid enrollment in every county and an increase of 17,000 jobs in Kentucky from Medicaid expansion at Monday's meeting of the legislature's Interim Joint Committee on Appropriations and Revenue.

Friedlander also discussed other benefits of Medicaid expansion, saying Kentucky health-care providers had received $892,973,500 in reimbursements from January to October of 2014, reports Brad Bowman of The State Journal in Frankfort.

Cabinet Secretary Audrey Haynes told Kentucky Health News on Tuesday that on the previous Friday, the cabinet had passed $1 billion in payments of federal money to health-care providers for treatment of people newly eligible for Medicaid: those with household incomes between 69 percent and 138 percent of the federal poverty level. About half the money has gone to hospitals, she said.

Still, many providers, particularly in rural areas, have reported cash-flow problems caused by delays in payment from Medicaid managed-care companies, lower-than-cost reimbursements and increased administrative burdens.

Also, some legislators have expressed concern about the cost of expanding Medicaid rolls, which grew more than predicted by a study that Beshear cited in his expansion decision. As the law outlines, the federal government will pay 100 percent of the costs until Jan. 1, 2017, when the state will begin paying a small share rising to the law's limit of 10 percent in 2020.

Republican Sen. Chris McDaniel of Taylor Mill, who is running for lieutenant governor on the gubernatorial slate headed by Agriculture Commissioner James Comer, asked Friedlander what Kentucky’s financial obligations would be because of the expansion in the next few years. He said that is uncertain.

Under initial estimates, based on the study by PriceWaterhouse Coopers, expansion was expected to cost the state only about $150 million a year when it was paying 10 percent of the cost. But the study only forecast that fewer than 300,000 newly eligible Kentuckians would sign up for Medicaid in the first year, but about 337,419 did.

To get updated cost projections, Beshear has contracted for a second analysis by an independent agency, which Friedlander said should be completed by mid-January, reports Ronnie Ellis of CNHI News Service.

The governor said the new study will speak for itself, reports Tom Loftus of The Courier-Journal. "I was confident after that initial report that we could certainly afford down the road over the next eight years to expand Medicaid and stay within our budget. I'm still confident," Beshear said.

Sen. Mitch McConnell faces diverse pressures on the question of repealing the federal health-reform law

Incoming Senate Majority Leader Mitch McConnell says he still wants to get rid of Obamacare, and the Kentuckian is "under rapidly increasing pressure from conservatives to pursue an aggressive path to repealing the landmark health care law," but it won't be easy, Jennifer Haberkorn reports for Politico.

Ardent conservatives are calling for repeated repeal votes under budget reconciliation, which requires only 51 votes, not the 60 usually needed to do significant business in the Senate. But establishment Republicans "barely mentioned Obamacare" the day after the election, Haberkorn notes. McConnell indicated that 60 votes are needed for repeal, and it takes 67 votes to override a presidential veto.

"McConnell has said that he wants to use the Senate appropriations process to starve funding to the law. When asked about his strategy on Wednesday, he said Republicans would be 'addressing that issue in a variety of different ways' and hinted at using reconciliation by saying that 'There are some things we can do with 51 votes'," Haberkorn writes. "Reconciliation is tricky — it would require Congress to pass a budget resolution, which is no easy task, and in the end, even a successful Obamacare repeal bill would just get vetoed anyway. And by the time they’re done, Republicans would have squandered potentially months of their new majority debating health care."

Several Republican sources say that McConnell will all but certainly hold an early, symbolic full repeal vote that is expected to generate support from every Republican and probably no Democrats. It will fail to overcome the 60-vote threshold for a filibuster. Beyond that, the Republican conference will collectively decide the strategy: a full-bore attack on as much of the law as possible, or a selective picking and choosing of the most vulnerable pieces of the law," such as its tax on medical devices and the coming mandate that employers of more than 50 people insure employees who work 30 or more hours a week.

"While Obamacare on the whole remains unpopular, there are pitfalls in any repeal strategy that includes popular parts of the law," Haberkorn notes. "That includes helping people with pre-existing conditions get covered, the subsidies that make insurance more affordable, and the exchanges, which is particularly popular in McConnell’s home state of Kentucky."

Still, "In some quarters, anything other than the full-scale assault is unacceptable," Haberkorn reports. "When McConnell stated on Fox News the other day the simple fact that Republicans couldn’t repeal the whole thing, the backlash was swift. The Senate Conservatives Fund, which backed his Kentucky Tea Party primary opponent, accused him of being insufficiently committed and of 'making excuses for why he won’t deliver on his central campaign promise.' McConnell’s aides had to send out statements restating how much he despised the health law."

Exit poll: Half of voters say Kynect works well, but almost as many say Obamacare went too far; 45% favor pot legalization

An exit poll of voters in Tuesday's election showed that half of them thought the state's health-insurance exchange, Kynect, is working well, but almost as many thought the federal health-reform law went too far.

Asked how Kynect is working, 21 percent of the electorate said it was working very well, and 29 percent said it was working somewhat well. About 13 percent were undecided, while 21 percent said it was not working too well and 15 percent said it was not working well at all.

Asked about the 2010 law that allowed creation of Kynect and subsidizes the health coverage obtained through it, 46 percent said it went too far, 22 percent said it was about right and 26 percent said it didn't go far enough.

The poll was taken primarily for the U.S. Senate race, and CNN cross-tabbed the two sets of results:

In another question that could be health-related, 45 percent of voters said they were in favor of legalizing marijuana in Kentucky while 52 percent opposed it. The poll report on CNN did not give the survey's margin of error.

Most Kentuckians who bought health insurance on Kynect will pay higher premiums next year

Most premiums for private health insurance purchased through Kentucky's health insurance exchange, Kynect, will increase in 2015.

Most of the people who have used Kynect have been added to Medicaid, the government health insurance program for the poor and disabled. Only about 85,000 Kentuckians used the site to purchase private plans.

Health insurance companies have filed their rate requests for 2015, and the state Department of Insurance has approved most of them, reports Adam Beam of The Associated Press.

Officials have approved a 15 percent average rate increase for the Kentucky Health Cooperative, which sold 75 percent of private plans on the exchange.

Humana and Anthem Blue Cross Blue Shield each sold 12.5 percent of the private plans on Kynect. Humana's premiums will rose an average of 12.8 percent, but rates for Anthem will go down an average of 4.3 percent, Beam reports. Rates apparently have not been set for two new companies that will join the exchange, CareSource and WellCare.

"Rates off the exchange are increasing, too, in both the small group and individual markets," writes Beam. For example, Time Insurance Co.'s individual rates will go up an average of 15 percent, and the small group rates for Time, Bluegrass Family Health and John Alden Life Insurance Co. will rise an average of 5 percent.

Department of Insurance spokeswoman Ronda Sloan told Beam that rates for large group plans were not available yet. The rate certification process will be finalized before open enrollment, which begins on November 15, 2014 and runs through February 15, 2015.

The averages can be misleading because that Kynect offers approximately 70,000 different rates, which vary depending on numerous variables, such as the type of plan, where people live, how old they are and whether they smoke.

Kynect was one of the few online health insurance portals that actually functioned when Obamacare launched a year ago. An estimated 521,000 Kentuckians have obtained insurance through the website, reducing the state's uninsured rate from 20 percent to 12 percent, Democratic Gov. Steve Beshear said in a recent video update.

Beshear said this sharp reduction in the uninsured proves that Kynect is working. Republicans say higher insurance premiums and difficulty finding doctors prove it isn't.

In Senate race, McConnell and Grimes differ on health care

By Cheyene Miller
University of Kentucky School of Journalism and Telecommunications

               The U.S. Senate race between Republican Sen. Mitch McConnell and Democrat Alison Lundergan Grimes has seen the candidates focus on several key issues, including the coal industry, the minimum wage and health care.

               The health-care issue has been almost unique among Senate races in that Kentucky is generally seen as a success story for the Patient Protection and Affordable Care Act. In August, Gov. Steve Beshear said 521,000 of Kentucky’s 4.3 million citizens had signed up for health coverage through Kynect, the state’s health insurance marketplace created under the law.

               According to a Gallup-Healthways poll, published in August, Kentucky reduced its percentage of uninsured more than any other state besides Arkansas, and lowered the percentage of uninsured in the state from 20.4 percent to 11.9 percent, thus covering two of every five uninsured Kentuckians.              

In addition to funding the expansion of Medicaid, the law requires Americans to either purchase private health insurance or enroll in some form of government assisted health care like Medicaid; requires insurance companies to cover people with pre-existing conditions and provide 10 elements of coverage in each policy; allows parents to keep their children on their health insurance until they are 26; and requires businesses employing 50 or more full time employees to provide health insurance, a provision that President Obama has suspended for a year.

McConnell says he wants to repeal the law “root and branch,” but has been more lenient toward the idea of keeping Kynect. In the Senate race debate on KET, McConnell suggested that Kynect was merely a website. However, repealing the law could pose issues for the newly insured in Kentucky because private insurance under Kynect uses federal tax credits, and provides free Medicaid coverage to citizens who earn up to 138 percent of the federal poverty level.

According to Douglas McSwain, a Lexington-based litigation attorney who specializes in constitutional and health-care law, the uprooting of the law would result in drastic changes to Kynect.

               McSwain said repealing the ACA “root and branch” would mean cutting the federal tax subsidies that are essential to Kynect’s survival.

“You take the exchange tax credit away, do you think for a minute that the website is going to stand?” McSwain asked.  “Nobody is going to buy policies.”

At a Kentucky Farm Bureau forum in August McConnell said Congress should have passed laws allowing health insurance to be sold across state lines, limiting malpractice lawsuits and making it easier for businesses to form health-insurance groups.

               McSwain said the law allows formation of such groups, and interstate regulation “is conceivable” but “The problem is we don’t have the infrastructure, regulatory-wise, to do that without having reached a compact or an agreement” among the states.

               A study on the effects of malpractice reform, published by the New England Journal of Medicine, found that Texas, Georgia and South Carolina did not see a significant reduction in the amount of doctor-ordered tests and scans after enacting reforms.  A five-person team of doctors performed the study, collecting data from 1997 through 2011.

               Grimes has only publicly discussed health reform on select occasions, taking a similar strategy to many Democrats in the 2014 midterm election because of the unpopularity of “Obamacare” and its namesake.  When she does mention health care, she talks about fixing and streamlining the law, as she did during the KET debate.

“I will not be a senator that rips that insurance from their hand,” Grimes said in reference to the half a million Kentuckians who’ve gained coverage under Kynect.  She said McConnell was in a “fictional fantasyland.”

Grimes has also talked about supporting an extension of Obama’s “grandfathering” of insurance policies that don’t comply with the law after he was criticized for not keeping his campaign promise that Americans could keep their doctor and health plan if they liked them.

               That controversy and other aspects of the law have led to negative feelings among Kentuckians about Obamacare.  A poll by Marist College for NBC News showed Obamacare had a 33 percent approval and 57 percent disapproval rating among Kentuckians, while Kynect had 29 percent approval and a 22 percent disapproval., while 29 percent of those polled said that they had never heard of Kynect and 21 percent were unsure of how to rate it. 

               At last report, about 80,000 Kentuckians had bought private insurance through Kynect and about 440,000 had used it to get on Medicaid – 320,000 of whom were eligible under the new rules and 120,000 under the what state officials call “old Medicaid.” The federal government pays about 71 percent of “old Medicaid” costs and, until the end of 2016, 100 percent of the newly eligibles’ coverage. In 2017, it will pay 95 percent of the new costs, and fall to the reform law's floor of 90 percent in 2020.

Cheyene Miller of London, Ky., wrote this story for “Covering the U.S. Senate Race,” a special course in the University of Kentucky School of Journalism and Telecommunications.

McConnell runs anti-Obamacare ad with doctor who connects pre-existing condition with cancellation of insurance

U.S. Sen. Mitch McConnell is running his first re-election commercial focused on the federal health-reform law, featuring a Somerset physician saying “As a doctor, I see how Obamacare hurts patients’ access to care.” She says McConnell is working for “common-sense health care reforms,” which are not specified, and is leading the fight to repeal the law.

Sandy Schuldheisz adds that her son has diabetes and her plan was “cancelled under Obamacare. Like many, we now pay more for less coverage.” That may cause an incorrect inference. "The Affordable Care Act also prohibits insurance companies from dropping or denying coverage to Kentuckians because they have a pre-existing condition, such as diabetes," notes Joe Sonka of Insider Louisville. Many policies were canceled because they didn't meet the law's requirements.
Sonka, a McConnell critic, reports that he "requested more background information on Schuldheisz’s personal situation from the McConnell campaign — such as her premium rate before and after, and whether she received insurance through her employer or individually," and the campaign has not provided it.

Gov. Steve Beshear told Sonka in a written statement, "We don’t know the specifics of the doctor’s claim about her family’s plan being canceled (although many folks with health insurance policies prior to ACA were allowed to maintain those older plans if they chose to). We do know that she could have shopped for affordable health insurance on kynect, and may have even qualified for a discount. The vast majority of Kentucky families who shopped on kynect qualified for some kind of payment assistance or subsidy. Finally, the ACA required insurers to offer standard, robust benefits such as preventive care and vaccinations, mental health coverage, maternity and infant care, and prescription drugs."

Sonka writes that Schuldheisz's home Pulaski County "ranked among the top fifth in Kentucky counties with the largest estimated decrease in their uninsured rate" as a result of Obamacare. "As of this April’s signup deadline, 8,134 residents in the county had signed up for health care coverage through the state exchange. Based on Kynect estimates that 75 percent of their enrollees did not previously have insurance, this means Pulaski County’s percentage of uninsured residents may have fallen from 18 percent to under 7 percent."

Kentuckians like Kynect coverage as long as it's not called 'Obamacare,' and some don't like to talk about it

By Molly Burchett
Kentucky Health News

Sticks and stones may break your bones, but words will never hurt you -- unless you're talking about the word "Obamacare" and its impact on the U.S. Senate race in Kentucky, the only Southern state to have both expanded Medicaid and set up its own health-insurance exchange under the federal health-reform law.

"The Affordable Care Act, known as 'Obamacare,' is a lightning rod in Kentucky, even though the state had one of the most successful rollouts in the nation," Al-Jazeera America reports in a five-part series on political issues in the state. The polarizing word is affecting the race between Senate Republican Leader Mitch McConnell and Democrat Alison Lundergan Grimes.

"In a state where 65 percent of registered voters disapprove of President Obama, even those who have signed up for coverage through Kynect don't want to think of it as Obamacare," Libby Casey and Philip Maravilla report.

In May 2013, Democratic Gov. Steve Beshear announced that he would use Obamacare to create the state health-insurance exchange and expand Medicaid rolls to cover Kentuckians earning up to 138 percent of the federal poverty level. That qualified hundreds of thousands of Kentuckians for the federal-state program, including Frank Dixon of Benham in Harlan County.

Dixon's 52-year-old body is damaged from decades working as a mechanic in coal mines where he injured his back, rotator cuff and shoulder. Like many Kentuckians who have worked hard to earn a good living all of their lives but lost jobs due to the mining industry or economic downturn, Dixon is thankful to have medical coverage and food stamps but "kind of ashamed to say it," he told Al-Jazeera:

"When asked if he supports Obamacare, Dixon lets out a long sigh and fidgets in his chair. “I don't know how to answer that,” he said. “Some things are left unsaid.” An NBC/Marist poll conducted in May found 57 percent of Kentuckians surveyed said they disliked Obamacare. But when asked about Kynect, only 22 percent disapproved. And yet they’re basically the same thing."

Republicans have more than taken notice of this sentiment, which may also be the reason Grimes hasn't made Kynect's success part of her campaign unless she is asked about it.

"Obamacare has been demonized by its opponents," Al Cross, director of the Institute for Rural Journalism and Community Issues at the University of Kentucky and publisher of Kentucky Health News, told Al-Jazeera. "And it’s easy to demonize because the first three syllables of the word are a word that most Kentuckians don't like."

Cross said that for Grimes to run on a platform of supporting the law would be risky, but could pay off: "I hope they do engage on the issue of health care because this state in many ways is the least healthy state in the country."

Aside from the questions of demonization and branding, Kentucky's health system has serious challenges, and the influx of Medicaid patients covered by Obamacare has come with new challenges for both patients and doctors, such as delayed approvals and burdensome paperwork from insurance companies.

Facing delays in preauthorization, some newly covered patients like Dixon are questioning the value of their Medicaid coverage. Others are just thankful to finally be able to see a doctor, Casey and Maravilla report.

Obamacare seems to be no plus for Kentucky Democrats, perhaps mainly because of the word's first three syllables

Though the federal health-reform law has helped cover more than half a million Kentuckians and cut the state's uninsured population by half, "there is little evidence it will help" Kentucky Democrats in the Nov. 4 elections, reports Abby Goodnough of The New York Times, who has been following Obamacare's implementation in the state.

“The campaign by the Affordable Care Act’s critics against it has been very effective in demonizing the phrase Obamacare and anything to do with the president,” Democratic Gov. Steve Beshear told Goodnough. “So I think you find a reluctance on the part of people, even though the law is benefiting them, to publicly acknowledge it.” Beshear noted that President Obama is highly unpopular in the state, and Goodnough notes that no one applauded during the six minutes that he spoke about the law at the Kentucky Farm Bureau's Country Ham Breakfast at the state fair last month.

Interest groups and Republican candidates in Kentucky "have run more than 10,000 broadcast television spots here since January 2013 that mention the law in a negative way, according to Kantar Media’s Campaign Media Analysis Group," Goonough reports. "Kantar found only one positive television ad, from Elisabeth Jensen, the Democrat challenging Rep. Andy Barr in the state’s Sixth Congressional District."

Many Democrats have urged their nominee for the U.S. Senate, Secretary of State Alison Lundergan Grimes, to use the issue, but "far from flaunting Kentucky’s strong enrollment numbers, Democratic candidates — most notably Ms. Grimes — have remained reticent about the law, even its successes."

Republican Sen. Mitch McConnell's re-election campaign hasn't run any advertising lately about the law, but still calls it the worst legislation in American history and says he wants it repealed "root and branch." But he has yet to explain, if that unlikely event happened, what would happen to the state exchange where more than 521,000 people got on Medicaid or bought private insurance policies.

Goodnough says McConnell has "hedged" on that, and links to an earlier story by her Times colleague, Jonathan Martin, who wrote: "When I pressed him about the politics of taking away Medicaid from those individuals that now have it, he suggested that was unlikely – even while still faulting Beshear for the decision. 'I don’t know that it will be taken away from them,' McConnell said of the expanded Medicaid coverage. Speaking about Beshear and Kentucky’s state government, he added: 'They’ve made the decision to expand it; they’re gonna have to pay for it.'"

State won't estimate cost of greater-than-expected Medicaid expansion for 'a few additional months' – after Nov. election

By Al Cross
Kentucky Health News

The Republican-controlled state Senate's budget committee chair wants to know how much Democratic Gov. Steve Beshear's expansion of the Medicaid program will cost, since enrollment in the federal-state program has exceeded the administration's expectations.

Medicaid Commissioner Lawrence Kissner told Sen. Bob Leeper of Paducah in a letter Sept. 8 that the administration won't be able to update the estimates "until a few additional months have passed and more data [are] collected" and "after the newly insured population has stabilized."

That pushes the date for new estimates past the Nov. 4 election, in which Republicans are making issues of the expansion's cost and the federal health-reform law that allowed it. U.S. Sen. Mitch McConnell has mentioned it in attacking "Obamacare," and Republicans trying to take over the state House have done likewise.

When Beshear announced in May 2013 that he would expand Medicaid eligibility to people with incomes up to 138 percent of the federal poverty level, using entirely federal money for the first three calendar years, he said it would cost the state $30 million in the 2016-17 fiscal year and $70 million in the 2017-18 fiscal year.

Those figures were based on an estimate by the Price Waterhouse Coopers accounting firm that 308,000 Kentuckians would become eligible for Medicaid but only 188,000 would enroll by 2017, based on calculations by the Congressional Budget Office. But so far, about 320,000 people have enrolled, more than double the 148,000 that the firm estimated would sign up by June 30.

At last report, about 521,000 people had obtained coverage through the state's Kynect health-insurance exchange. About 80,000 of them bought private insurance, and 120,000 qualified for what state officials call "old Medicaid" for a variety of reasons: they were children, blind, disabled or had income less than 69 percent of the federal poverty level, the old limit for the program.

The federal government pays about 71 percent of "old Medicaid" costs and, until the end of 2016, 100 percent of the newly eligibles' coverage. In 2017, it will pay 95 percent of the new costs, falling to the reform law's floor of 90 percent in 2020.

Kissner told Leeper that the administration needed more experience with the new enrollees, and better estimates of projected employment in 2017-18, other "key economic indicators" and how many Kentucky households will have incomes above or below 138 percent of the federal poverty level.

Leeper could not be reached for comment. For a copy of Kissner's letter and related materials, click here.

Health-board smoking bans that Supreme Court struck down are still being obeyed: 'Everybody loves it,' advocate says

By Melissa Patrick
Kentucky Health News

Three counties in Kentucky with unenforceable smoking bans continue to be smoke-free by the people’s choice.

Clark, Madison and Woodford counties have smoking bans that can’t be enforced because they are regulations of county health boards, which the Kentucky Supreme Court ruled in June do not have the power to ban smoking in public places. But officials in each county reported that most of the establishments in these counties continue to be smoke-free by choice.

“We are finding, in general, public spaces and restaurants are still complying with regulations as if it is still enforceable,” said Christie Green, public-information officer for the Madison County Health Department. “It seems as if the general public prefers this.”

In Versailles, the city council “hadn’t heard from one single tax-payer who is opposed to it,” recently resigned city council member Sonny Jones said in an interview before his resignation.

Scott Lockard, director of public health in Clark County, said likewise. “The community has remained smoke free. The public has demanded this, ” he said, and as far as he was aware “No businesses have gone backward in this.”

That doesn’t surprise Ellen Hahn, director for the Kentucky Center for Smoke-Free Policy and the state’s leading smoking-ban advocate. “When communities go smoke free, everybody loves it,” she said.

The anti-smoking regulations can’t be enforced, advocates said. “If enforced, a lawsuit might result,” Lockard said. “We have no active enforcement right now in Clark County.”

The court ruled in a case from Bullitt County, where a local judge had blocked enforcement.

Each of the other counties is handling the issue somewhat differently.

Woodford County, out of “respect for the cities” of Midway and Versailles, will let them determine whether they want to reinstate their previously enacted smoking bans before the county fiscal court makes a decision for the unincorporated area of the county, County Attorney Alan George said, “because the bulk of the affected business is in the city.”

Midway passed a new anti-smoking ordinance Aug. 18 and Versailles plans to hold its first reading on one Sept. 2.

Madison County plans second reading and passage of its smoking ordinance for Sept. 9. Berea is scheduled to do likewise Sept. 2.

Clark County has “no forward actions” or “no ordinance drafted” at this time, Lockard said. Asked if officials are waiting on the Nov. 4 election to move forward, he said that “no one had come out and said the election will play a role,” but he noted that the Winchester mayor and the county judge-executive have opponents.

The Supreme Court ruling was a great disappointment to smoke-free advocates. Betsy Janes, coordinator for Smoke Free Kentucky, said several health boards had been ready to implement smoke-free regulations, but were waiting on the Supreme Court. These plans obviously have had to change.

“It was a major blow, but the good thing is that it is very clear who has the authority to do this now,” Janes said. “Fifty-five percent of Kentuckians want to be smoke free. We are losing 1000 Kentuckians a year to second hand smoke,” based on research that has determined its effects.

While Hahn said the decision was a “step backwards for Kentucky,” she also said her center is “busier than ever” working with fiscal courts to create smoke-free laws on the local level. She said there are 35 city or county ordinances in effect, covering 31 percent of Kentuckians.

The Kentucky Chamber of Commerce supports statewide smoking ban, which has never come to a vote in either chamber of the legislature.

“Twenty-four other states have statewide smoke-free laws and we want to not be the last to join them,” said Ashli Watts, the chamber’s public-affairs manager.

While Clark County is not pursuing a smoke-free ordinance now, the health department is actively educating the public about the benefits of such laws and plans to be a strong advocate to get something passed, Lockard said.

“We are finding overwhelming positive response to smoke-free,” he said. “The Board of Health and health department will work in any way possible to get a law on the books.”

Lockard also voiced his hope that school boards will pass smoke-free policies in schools, which he said should be attainable because no legislation is needed.

“There are 174 school districts in Kentucky and less than 40 of them have smoke-free policies on their campuses,” Lockard said. “If we could have all schools smoke-free, that would have a major impact on our communities.”

Lockard reflected on what Tom Frieden, director of the federal Centers for Disease Control and Prevention, said in his recent visit to Kentucky, that the most important changes Kentuckians need to make to improve their health are to stop smoking, decrease secondhand smoke exposure, and to exercise.

Beshear cites examples of health reform's benefits, while McConnell keeps up criticism, at Farm Bureau's ham breakfast

By Al Cross
Kentucky Health News

Democratic Gov. Steve Beshear and Republican U.S. Sen. Mitch McConnell squared off on health-care reform for the second straight year at the Kentucky Farm Bureau Federation's annual Country Ham Breakfast at the Kentucky State Fair last week.

Beshear, who spoke first, noted that a year earlier he had called for politicians to stop "partisan bickering" about the law and told Kentuckians that they didn't have to "like the president or the Congress" to investigate its benefits. "Over half a million Kentuckians took my advice," he said. "Young and old, black and white, singles, families, Democrats, Republicans, city folks, country folks -- you went looking for the facts, and what you found was high-quality, low-cost health insurance."

Beshear noted that Kentucky is second in the nation in the estimated reduction of uninsured population, and gave the reductions in four counties: Christian, from 17 percent to 12 percent; Montgomery, from 18 to 9.5; Laurel, from 18;7 to 10.1; and heavily Republican Monroe, from 21 to 11.5.

He also cited two individual examples: Casey County farmers Frank and Renee McAninch, who couldn't afford insurance but now pay nothing, who skipped doctor visits, ignored health concerns and paid "outrageous out-of-pocket costs;" and Joe Paul Mattingly of Marion County, a state Farm Bureau director who found "cheaper, better insurance" on the state health-insurance exchange.

Beshear said Frank McAninch had skin cancer removed, and Mattingly is not receiving a subsidy but is paying 20 percent less for coverage than before. "As Joe Paul said, he chose to be part of the solution, not part of the problem," Beshear said, adding that critics of the law should do likewise.

McConnell was having none of it. Noting that Beshear didn't use the word "Obamacare," the senator said, "He just doesn't want to say it, and I don't blame him."

McConnell delivered his usual litany about the law -- its cuts in payments to health-care providers, its taxes on medical devices and insurance policies, and the higher premiums, co-payments and deductibles being paid by many people.

Citing a study by the Congressional Budget Office, McConnell said Obamacare “will cost 2.5 million jobs.” The study says the predicted reduction, through 2024, will come “almost entirely because workers will choose to provide less labor,” not because jobs will be eliminated.

As for the Medicaid expansion that is responsible for about three-fourths of the 521,000 people with Kynect coverage, McConnell said, "I do worry about our state government and its ability to meet these commitments in the future."

Beshear has cited studies predicting that the expansion will pay for itself by expanding the health-care industry and creating jobs. Republicans have said they don't believe those predictions but generally have been unwilling to say that the expansion should be ended, which would leave hundreds of thousands of people without coverage. McConnell has said his criticism of the law is "not connected" to the state insurance exchange.