Hope is high for a House floor vote and passage of a statewide smoking ban, but the Senate remains doubtful

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill to ban smoking in public places and places of employment is headed to the House floor yet again, and its sponsor says it will finally get a vote. But its chances in the Senate remain doubtful.

Rep. Susan Westrom

"I feel very confident that we will get a floor vote," Rep. Susan Westrom, D-Lexington, five-year sponsor of the legislation, said after Thursday's committee meeting. "I am shooting for next Wednesday."

House Bill 145 passed the Health and Welfare Committee 11-4, with all Democrats and two Republicans on the panel for it and four Republicans opposed.

Westrom said the bill is not a smoking ban, but simply asks smokers to step 15 feet outside to smoke. She said, this is "not a huge sacrifice, but the benefits are so incredible."

The bill also requires those smoking electronic cigarettes and hookahs to step outside, which could cause a "battle," Westrom said.

The legislation got to the House floor last year, but didn't get a vote, and has never gotten out of committee in the Senate. Polling shows a clear majority of Kentuckians support banning smoking in indoor public places, but almost 30 percent of Kentuckians smoke, tops in the nation. The state also is No. 1 in lung cancer and deaths from it.

Two Republican senators, pediatrician Ralph Alvarado of Winchester and lawyer Julie Raque Adams of Louisville, chair of the Senate Health and Welfare Committee, sat with Westrom and Rep. David Watkins, D-Henderson, a retired physician, before the committee.

Alvarado gave an impassioned reading of his op-ed that was in the same day's Lexington Herald-Leader to the committee. "Smoking is killing Kentucky, literally and fiscally," he said.

He said an estimated 950 Kentuckians die every year because of secondhand smoke; exposure to it costs Kentucky more than $128 million every year; children exposed to secondhand smoke suffer from repeated ear infections, bronchitis, pneumonia and asthma; and secondhand smoke is a proven cause of heart disease, cancer and stroke in non-smoking adults.

By passing the bill, "The General Assembly can save more lives with this legislation than I can throughout my entire medical career," Alvarado said. Democratic Gov. Steve Beshear supports it.

Adams, who will be sponsoring the legislation in the Senate, told the committee, "We need to see a vote on the floor. We need to talk to our senators. We need to keep up the advocacy because Kentuckians deserve better."

Senate Republican Floor Leader Leader Damon Thayer told Jack Brammer of the Herald-Leader that there is "not much sentiment" for the bill in the Senate: "Let the free market work this out."

Republican Bob DeWeese, a doctor from Louisville, voted for the bill. He said the title of representative was fleeting, but "I'm a doctor for life."

Newly elected Rep. George Brown Jr., D-Lexington, noted that he voted against the smoking ban in Lexington many years ago. "Since that time, I've had an awakening and I understand that the collective rights of citizens are much more important than those of individuals."

Rep. Robert Benvenuti III, R-Lexington, said "liberty interests have to be balanced" between the rights of smokers to smoke in the workplace versus the rights of others to be healthier.

Newly elected Rep. Phil Moffett, R-Louisville, said "I support it at the local level and that is where is should reside," and asked Westrom why the legislature shouldn't just make tobacco illegal "if it is that devastating."

Westrom suggested Moffett ask the Kentucky Farm Bureau Federation about that. She said in December that Farm Bureau has been the main obstacle to the bill.

About 5,000 farmers in Kentucky grow tobacco, a greatly reduced number from the days of the federal tobacco program, which ended 10 years ago. Farm Bureau spokesman Dan Smaldone said in December that the organization continues to oppose the legislation because it invades the private-property rights of business owners.

Asked why a farm organization cares about that, Smaldone wrote in an email, "KFB's membership supports policy for rural issues that fall outside of the agriculture industry, including educational and economic issues that impact their local communities. The organization has policy on the issue because its membership determined it was important to take a position on it."

As for the local approach, Westrom said after the meeting that too many local communities have not taken the initiative to pass smoking bans.

About one-third of Kentuckians are covered by strong local smoke-free laws, with 24 communities with smoke-free laws that cover all workplaces and enclosed public places, according to the Smoke-Free Kentucky Coalition website.

Westrom, Alvarado and committee Chair Tom Burch, D-Louisville, said they thought the bill would pass the House, but none were sure about the Senate. Westrom noted that Senate President Robert Stivers, R-Manchester, has been vocal against the bill.

"The wonderful thing about Sen. Stivers is that he understands how important the cancer research center is at the University of Kentucky," Westrom said, noting Stivers' call to reopen the 2014-16 state budget to authorize the project: "If we are going to invest that amount of money for a cancer research center, the best thing we can do . . . is make sure the entire state is setting the example of a smoke-free state."

Smoke-Free Kentucky Chair Amy Barkley said, "If the House passes it and puts the ball in their court . . . I'm just going to be optimistic that they will listen to their voters. We know that 66 percent of the voters support a statewide smoke-free law and that crosses all parties and regions of the state." That is the figure in the latest Kentucky Health Issues Poll; a Bluegrass Poll put the figure at 57 percent.

Public opinion will make the difference this year, Westrom said. "Some portions of the state are more that 74 percent approval; 70 percent of the people who used to smoke are in favor of this; and an average of 60 percent of those in rural areas are in favor of smoke-free."

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.

Health-care forum examines 'incredible change' in Kentucky's health-care system, looks forward to more access to care

By Molly Burchett and Al Cross
Kentucky Health News

What does health-care reform mean to Kentucky? What impact has Medicaid expansion had? Can we work together to do care differently in Kentucky? Answers to these questions and more were offerd by national, regional, and local health care experts Sept. 16 in Louisville at the Foundation for a Healthy Kentucky's annual Howard L. Bost Health Policy Forum.

This year's topic was "Doing Care Differently," but as foundation chair David Bolt, deputy director of the Kentucky Primary Care Association, told the crowd, "It could have just as easily been named after the Bob Dylan song, 'The Times They Are A-Changin'."

As a health-care provider for 44 years, Bolt said, "I have lived through almost every change since the implementation of Medicare and Medicaid. And I am actually excited about the changes I see on the horizon." He said he thinks the late Dr. Bost would look at what Kentucky is doing and say," It's about time we moved away from a treat-'em-and-street-'em mentality to integrated health care delivery services and systems rooted in accountable outcomes and founded in a value-drive system of improving health."

One of the biggest recent changes in Kentucky health care is Gov. Steve Beshear's expansion Medicaid at the beginning of the year, which offered coverage to Kentuckians under 65 in households up to 138 percent of the federal poverty level. As a result, Medicaid is now the largest health-care payer in the state, serving 1.1 million Kentuckians, one out of every four, Cabinet for Health and Family Services Deputy Secretary Eric Friedlander told the crowd.

"We had incredible enrollment. It's an incredible change." said Friedlander. "We hope it is a change for the better."

Friedlander said enrollment in every county exceede estimates for the state by the accounting firm PriceWaterhouse Coopers, based on estimates from the Congressional Budget Office. Those estimates anticipated 55 percent of eligible persons enrolling in the first year, leveling out at 70 percent in future years. Instead, enrollments through June were almost double the prediction.

Medicaid paid more than $284 million to Kentucky health-care providers in the first half of this year for treating the newly eligible Medicaid beneficiaries, with hospitals receiving 48 percent of those reimbursements, Friedlander said. He said that number will be $1 billion to $2 billion by the end of the year. (Medicaid payments sometimes take months to complete.)

The federal government is paying the entire cost of the newly eligibles through 2016. State officials have said that they won't be able to update cost estimates for 2017 a few more months because additional data must be collected about enrollees after the insured population has stabilized.

"Medicaid expansion is not static," Friedlander said. "It is dynamic, and the individuals that make up that enrollment are constantly changing."

Friedlander said employment in Kentucky health care has increased by 3,800 jobs, but the study estimated that 7,600 jobs would be added in the first year. This means enrollment is almost double what was projected yet job expansion is almost half. That undercuts Beshear's contention, based on the study, that Medicaid expansion will pay for itself by adding heath-care jobs.

As more Kentuckians get insurance, there may be shortages of primary-care doctors, especially in rural areas of states like Kentucky, reports Kaiser Health News. That need could be overstated, Sheila Schuster, a clinical psychologist and executive director of the Advocacy Action Network, said at the forum.

Kentucky has 3,929 advanced practice registered nurses, Schuster said, 54 percent more APRNs than in 2010. A new state law that took effect July 15 "removed a barrier that was keeping them from opening practices," she said. The law allows APRNs to prescribe non-narcotic drugs independently after they have prescribed under physician supervision for four years.

The law was passed after negotiations among the Kentucky Medical Association, the Kentucky Academy of Family Physicians and the Kentucky Coalition of Nurse Practitioners and Nurse Midwives. Schuster suggested that other such compromises are needed to expand access to health care.

"We aren't playing very well with each other in the sandbox," she said, adding that turf battles need to be set aside to keep health-care innovation people-centered.

The forum was co-sponsored by KET, Louisville's Health Enterprises Network, the Kentucky Health Information Exchange, the Kentucky Medical Association and Leadership Kentucky.