Baucus sees a health-reform 'train wreck,' fearing insurance exchanges won't be ready

Max Baucus (J. Scott Applewhite, AP)

Senator Max Baucus, who as Senate Finance Committee chair helped write the health-care reform law, has become the highest-ranking Democrat to publicly voice concerns about its implementation, saying he thinks it’s headed for a collision with itself.

“I just see a huge train wreck coming down,” the Montanan told Health and Human Services Secretary Kathleen Sebelius during a budget hearing.

Matt Gouras of The Associated Press notes that polls show that Americans are confused by the complex law, which is designed to cover about 30 million uninsured people through a mix of government programs and tax credits. Baucus told Sibelius he’s “very concerned” that new health insurance exchanges will not open on time in every state and residents will not have enough information to make choices even if they do open on time, as Kentucky's seems likely to do.

"The administration’s public-information campaign on the benefits of the Affordable Care Act deserves a failing grade,” Baucus lectured. “You need to fix this.” Baucus’ office later told Gouras that the senator still thinks the Affordable Care Act is a good law, but questions its roll-out.

Sebelius said that the administration is on track to fully implement exchanges in January, and to be open for open enrollment on Oct. 1, 2013, reports Gouras. Kentucky is among the states that have chosen to build a fully state-based exchange. Others have chosen a state-federal partnership exchange, or defaulted into a federally facilitated exchange. The map below shows the lay of the land about that decision. Yellow states have defaulted to a federal exchange, light blue states are planning for a partnership and blue states have chosen a state-based exchange.

Map provided by the Kaiser Family Foundation

Feds letting Arkansas privatize Medicaid expansion; idea could spread like wildfire, as in Florida, but cost questions remain

Arkansas has turned heads nationally with its preliminary plan to expand Medicaid using the private insurance market, showing that the Obama administration is willing to give states more flexibility than expected in expanding the program.

Health and Human Services Secretary Kathleen Sebelius has agreed to a proposal by Arkansas Gov. Mike Beebe to reject the Medicaid expansion but use federal money to buy private health insurance for the 200,000 people who would have been covered under ordinary expansion, reports Sandhya Somashekhar of The Washington Post.

States that have come down on either sides of the Medicaid-expansion issue may reconsider their decision in light of the Arkansas proposal, said Sara Rosenbaum, a health law professor at George Washington University. "If Arkansas is allowed to do this, I expect it to spread like wildfire," Rosenbaum told the Post.

The first place could be Florida, where a state Senate committee rejected Republican Gov. Rick Scott's expansion plan and proposed a privatization plan like that in Arkansas. Last week, a House committee voted to reject any expansion of the program. Scott "made it clear he was not going to lobby the Legislature on Medicaid," preferring to emphasize other issues, The New York Times' Lizette Alvarez reports. For coverage from the Tampa Bay Times and The Miami Herald, click here.

Could the wildfire spread all the way up to Kentucky?

Gov. Steve Beshear has said he wants to expand Medicaid in Kentucky if the state can afford it, but many Republican lawmakers oppose the idea, saying it would not be fiscally responsible. On the national level, 26 states and the District of Columbia have expressed a desire to expand Medicaid, 17 have said they reject it and seven are undecided, according to the nonpartisan Kaiser Family Foundation.

A more flexibile arrangement could be a game changer because it makes expansion more appealing, especially for states where expanding Medicaid has been politically unpopular and polarizing. in Arkansas, which has a Democratic governor and a Republicna legislature, officials say that from an ideological standpoint, using private insurance appeals to lawmakers from both parties, reports Somashekhar. She reports that even Democratic-led states might prefer this arrangement because it gets rid of some bureaucratic hurdles.

However, there are questions about cost. The Congressional Budget Office estimates that private insurance plans cost $3,000 more per person than Medicaid, reports Somashekhar. On the other hand, Arkansas officials say the move could ultimately save money in administrative charges along with other cost-control measures.

Although the Arkansas proposal is not concrete, it provides proof that the Department for Health and Human Services encourages innovative, state-based approaches to promote expansion. Many states may develop a new route best suited to their specific needs, without having to leave federal money on the table. (Read more)

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

By Al Cross
Kentucky Health News

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

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

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

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

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

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

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

Kasich of Ohio is fifth Republican governor to accept Medicaid expansion; he and others cite need to protect rural hospitals, poor

Several Republican governors have decided to expand Medicaid under federal health-care reform, saying their conservative principles were outweighed by a need to protect their state's rural hospitals and low-income people. Yesterday, the governor of one of the biggest states got on the bandwagon.

John Kasich of Ohio joined Jan Brewer of Arizona, Brian Sandoval of Nevada, Susana Martinez of New Mexico and Jack Dalrymple of North Dakota in saying they will take heavy federal subsidies to expand the program to households with incomes up to 138 percent of the federal poverty threshold.

Democratic Gov. Steve Beshear of Kentucky has said he wants to expand Medicaid if Kentucky can afford it, and he expects to get cost estimates around the end of March.

While Kasich is not an "Obamacare" supporter, he said expanding Medicaid “makes great sense for Ohio” because it would save $235 million over the next two years and free about $100 million in local funds for mental-health and addiction services, reports The Columbus Dispatch.

Kasich said the decision could extend health coverage to as many as 578,000 uninsured Ohio residents, and could keep everyone else’s health insurance premiums down because there won’t be so many uninsured people going to emergency rooms for their medical care, reports David Nather of Politico.

Kasich emphasized that he would like to see the 2010 law repealed, but the federal money it would pump into the state — about $13 billion over the next seven years — was too much to pass up, reports Stateline. The federal government will pay the full cost of expansion through 2016; then  states will have to pitch in, rising to a limit of 10 percent by 2020.

Brewer likewise said it doesn't make sense for Arizona to pass up federal dollars, reports Howard Fischer of the Arizona Daily Sun. "We will protect rural and safety-net hospitals from being pushed to the brink by growing their cost in caring for the uninsured," Brewer said. She also said the expansion will create enormous economic benefit, inject $2 billion into the Arizona economy, save and create thousands of jobs and provide health care to hundreds of thousands of low-income individuals, reports Fischer.

Brewer said going along with expansion will save Arizona money because the costs of providing care to the uninsured are not simply absorbed by hospitals but passed along through increased insurance premiums. Supporters of the expansion hope the five Republicans' decisions will prompt more GOP governors to follow suit. Twenty governors from both political parties are still undecided. (Read more)

Oregon may show the way for Kentucky in drug treatment

In facing up to its need for more drug-treatment facilities, Kentucky could learn some lessons from Oregon, Courier-Journal reporter Laura Ungar writes in the third and last part of her package of stories about drug treatment, or lack of it, in our state: "Oregon, like Kentucky, is a largely rural state with about 4 million people — and a substantial prescription-drug abuse problem. But Oregon has acted more quickly and aggressively to tackle treatment." She cites examples:

• Oregon is spending about $51 million annually on substance abuse treatment, $11 million more than six years ago. "Kentucky’s Department of Behavioral Health, Developmental and Intellectual Disabilities spends $29 million a year , and hasn’t increased that amount in more than a decade."

• Medicaid, the federally subsidized health-insurance program for the poor and disabled, covers substance abuse treatment in Oregon, "while Kentucky, with a few exceptions, does not."
• Oregon admits more than twice as many addicts for treatment, and "Oregonians are much more likely to receive intensive treatment: "10 percent of treatment admissions were to long-term, residential facilities, compared with 1.1 percent in Kentucky."
• Kentucky had a much higher rate of deaths from drug overdoses in 2008, the most recent year available — 17.9 per 100,000 compared with 11.7. "Health experts say effective treatment leads to fewer overdoses." (Read more)

Kentucky's pill-mill problem and law to fight it get national airing, with issues of patient privacy versus public health debated

Kentucky's "pill problem" went more public Thursday when David Hopkins, head of the state's prescription drug monitoring program, told the National Conference of State Legislatures the true extent of our prescription pain pill addiction. Maggie Clark of Stateline reports that lawmakers "shook their heads in disbelief" when Hopkins said the state's doctors issued 60 million prescriptions for the 4.4 million Kentuckians in August of this year alone. The stark admission was a way to start talking about where patient privacy ends and public health concerns begin, Clark writes.

Kentucky is among 42 states with operational prescription-monitoring laws but few others require physicians to use the database to chronicle each patient and their drug use before prescribing as Kentucky does. And while the commonwealth allows its law-enforcement officers access to the database, the database is not controlled by the attorney general's office but, as a nod to patient privacy, by the Cabinet for Health and Family Services. In Vermont, legislators fought that battle earlier this year, with police there needing a warrant to access it. When Kentucky's law enforcement officers were surveyed about the law in 2010, 73 percent said they found the tool "excellent" for obtaining evidence.

At the conference, a report citing a Centers for Disease Control review explained that data collected through 2005 in a limited number of studies shows that having a prescription drug monitoring program in place had no clear impact on overdose mortality, Clark reports.

Rural states with declining immunization rates have increasing incidence of whooping cough

In the state that once had the highest immunization rate, Vermont's medical community is not so proud of anymore. Fewer people are vaccinating their children in the nation’s most rural state, reports Dr. Wendy Mahoney, a private practioner in the state. But Vermont isn't alone. Stories about declining immunization have come in from across rural America, Mahoney writes in the Daily Yonder, and they "come in the midst of a pertussis outbreak the likes of which Vermont has not seen in years, if ever." Pertussis is whooping cough.

Mahoney says she can find one reason for the recent outbreak: a new law in her state, like some in other rural states, that allows parents to exempt their children from required vaccinations "because of a personal, moral, or other belief." Mahoney says many rural residents use the exemption, which she finds hard to fathom in the face of scientific advances that prove that vaccination has ended smallpox, wiped out polio in most of the world, and controlled measles, rubella, tetanus, diphtheria, influenza type b and other infectious diseases.

The top map shows the estimated percentage of children enrolled in kindergarten who have been exempted from receiving one or more vaccines in the 2011–12 school year. Comparison with the other map shows that states with large numbers of exemptions are those where whooping cough is making a comeback. (Centers for Disease Control maps)

A comparison between states with low vaccination coverage rates and those reporting higher numbers of whooping cough cases shows some, though not consistent, overlap. (Read more)

Are fallacies about health reform becoming accepted wisdom? Former New York Times editor Bill Keller says he fears so

"A number of fallacies seem to be congealing into accepted wisdom" about the Patient Protection and Affordable Care Act, former New York Times editor Bill Keller writes for the paper. The myths, he says, are that (1) the law is killing jobs, (2) it's a federal takeover of the health system, (3) the free market would be better, (4) states can fix the problems with health insurance, and (5) the law is a political loser. Here's a capsule of Keller's counterpoints:

(1) Jobs: While some workers "no longer so dependent on employers for their health-care safety net may choose to retire earlier or work part-time," Keller writes, their jobs will be open for others, and he cites FactCheck.org's latest debunking of the job-killer claim.

(2) Takeover: "The main thing the law does is deliver 30 million new customers to the private insurance industry," Keller writes, with emphasis. "Insurance will be governed by new regulations, and supported by new subsidies . . . but the share of health-care spending that comes from the federal government is expected to rise only modestly."

(3) Marketplace: "To the extent there is a profound difference of principle anywhere in this debate, it lies here," Keller writes. He says giving people tax credits to buy their own insurance and care could reduce wasteful spending, but quotes Karen Davis, president of The Commonwealth Fund: Ten percent of the population accounts for 60 percent of the health outlays. They are the very sick, and they are not really in a position to make cost-conscious choices.”

(4) States: "Some states are too poor to adopt worthwhile reforms. Some are intransigent, or held captive by lobbies," Keller writes, noting that the law "underwrites pilot programs to reduce costs, and gives states freedom — some would argue too much freedom — in designing insurance-buying exchanges."

(5) Politics: Because most of the law won't take effect until 2014, "so there are not yet testimonials from enthusiastic, family-next-door beneficiaries. This helps explain why the bill has not won more popular affection. It also explains why the Republicans are so desperate to kill it now, before Americans feel the abundant rewards," Keller writes, calling on Democrats to "mount a full-throated defense." (Read more)

Governors in both parties undecided on whether to expand Medicaid; seeking answers to several questions

There is hesitation among governors on both sides of the aisle regarding whether or not to expand Medicaid, which would cover millions more Americans under the program for the poor and disabled.

"At least seven Democratic governors have been noncommittal about their willingness to go along," N.C. Aizenman and Karen Tumulty report for The Washington Post. Gov. Steve Beshear has not indicated whether he will expand coverage in Kentucky, but previously expressed concerns about the costs associated with the move, and state House Republican Leader Jeff Hoover has said he should not. Kentucky would have to start paying part of the extra cost in 2017, and 10 percent of it by 2020. Several Republican governors have said they will not participate, while others say they have not decided.

The issue is surely a major discussion topic at the National Governors Association meeting this week in Williamsburg, Va. Questions remain unanswered: "Will states that opt in have the option of scaling back in future years? If a state that opts out decides it wants to participate at some later point, will the federal government still pay nearly the full cost of covering those who become newly eligible for Medicaid? And can a state participate only partially — for instance, by raising the income cutoff for its program to a level lower than the ceiling envisioned in the law, which is set at 133 percent of the federal poverty line?" Aisenman and Tumulty ask.

NGA Executive Director Dan Crippen said states are confused over what to do. The association has sent a list of questions to Secretary of Health and Human Services Kathleen Sebelius about the issue. "States need to be making these decisions now, and it's hard to make them if you don't have clarity," said Matt Salo, director of the National Association of Medicaid Directors.

Sebelius has said she will address concerns during meetings that will take place in various cities starting July 31. There is no deadline yet for when states must choose whether or not to expand. (Read more)

Former head of Massachusetts health exchange says it's better to offer fewer, well-defined plans than set general criteria

With  Kentucky stakeholders discussing their options to set up a state-run health insurance exchange — something Gov. Steve Beshear said last week he intends to do if the Affordable Care Act is upheld by the U.S. Supreme Court — research shows the fewer plans offered in the exchange, the better.

An article in Health Affairs says officials should follow the lead Massachusetts' health-reform system when creating their own exchanges. "A hands-on exchange with the power to set standards on top of the federal health-care law will help prevent consumers from being 'overwhelmed' by the process of buying insurance," reports Sam Baker for The Hill's global affairs blog.

The Health Affairs article's lead author, Rosemarie Day, is a former deputy director of the Massachusetts exchange. She said consumers prefer choosing from "a handful of carefully vetted, clearly described health-care plans," Baker reports. The model used in Utah to allow any plan that meets criteria to be featured in the exchange is less popular, the paper found, but was more popular among conservatives.

"Findings from consumer research emphasized the value of limiting insurance plan choices on the exchange," the analysis states. "Specifically, early focus groups showed that consumers wanted four to six carrier options at 'low, medium and high' benefit levels." (Read more)

In bipartisan way, political leaders push passage of 'pill mill' bill

A bipartisan group of political leaders issued a call today "to pass a bill that will help the state battle one of its most significant threats – prescription drug abuse," a press release from Gov. Steve Beshear's office said. Beshear, Attorney General Jack Conway, House Speaker Greg Stumbo, Senate Republican Floor Leader Robert Stivers, Sen. Jimmy Higdon, R-Lebanon, and House Judiciary Committee Chairman John Tilley, D-Hopkinsville, said the legislature should pass House Bill 4 when it returns to Frankfort for its final day April 12.

"Since the beginning of 2012, more than 400 Kentuckians have been hospitalized because of prescription drug overdoses – a statistic that the leaders say underscores the crucial need to pass this bill in this legislative session," the release said. "Kentucky has the nation’s sixth-highest rate of prescription drug overdose deaths, at nearly 18 deaths per 100,000."

Conway said in the release, “I'm hopeful everyone, including the medical community, can get on board with House Bill 4 to ensure that we don't lose another generation in Kentucky to prescription drug abuse.” The bill would move the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system to Conway's office from the Kentucky Board of Medical Licensure, which is controlled by doctors and has done little to rein in "pill mills" that churn out prescriptions for painkillers.

"Law enforcement members warn that Ohio, Tennessee, West Virginia and Florida have passed legislation similar to HB 4 to address pill mills, and failing to pass similar legislation could create a diversion effect in which Kentucky could become a source state for prescription painkillers," the release said.

Stumbo, who preceded Conway as attorney general, said in the release, “Given the true epidemic we are seeing, we cannot afford to wait another year to try to pass this again.” In October, Stumbo, Beshear and Conway "announced creation of an advisory board of physicians, dentists, nurses, and pharmacists to work with KASPER officials and law enforcement professionals to create guidelines for generally accepted prescribing practices among different medical disciplines," the release said. "These criteria will be used as a guide for when a prescriber or dispenser’s KASPER reports may be flagged for unusual prescribing activity."

The bill would require all prescription providers to register and use KASPER, require pain management clinics to be owned by a licensed medical practitioner, make medical licensure boards investigate prescribing complaints within four months. 

Spend $1 on smoking cessation, save $3 in health costs, Massachusetts study finds

Every $1 spent on smoking cessation in Massachusetts, saved $3 in health costs, a study of low-income Bay State residents found. That could bode well for the impact of a new smoking-cessation benefit in Kentucky's Medicaid program.

Massachusetts added a smoking-cessation benefit to its Medicaid program in 2006 and "let members choose from any FDA-approved options," reports Martha Bebinger for National Public Radio.

Researchers at George Washington University "found that members who quit saved three times the cost of the program in fewer heart-related hospitalizations after just over one year," Bebinger reports. "The study does not take into account the benefits of avoiding cancer or other long term smoking related illnesses."

Kentucky ranked 36th in the nation for tobacco prevention spending. Though it received $389 million in tobacco-settlment funds in fiscal year 2012, and ranks first or second in tobacco use, Kentucky spent just $2.2 million of that on prevention of tobacco use. It recently added a smoking-cessation benefit to Medicaid, a program that is funded mainly by the federal government but administered by individual states.

Recession has hit health departments hard: 23,000 jobs (15%) lost, core funding cut

Funding and job cuts as a result of the economic recession have weakened the impact public health departments have on their communities, says a series of articles published in the Journal of Public Health Management and Practice.

"Continued cuts to public health services will have an unsatisfactory impact on the health of individuals and the community," said Dr. Lloyd F. Novick, the journal's editor-in-chief. "There is a heightened vulnerability at the present time for adverse health outcomes. Above all, the realization of the vital need to maintain resources for our public health delivery system is imperative."

In 2009, 23,000 jobs in public health departments were eliminated, 15 percent of the total. By 2010, more than half the agencies had a cut in core funding. As they scramble to make do with their new bottom lines, more cuts are expected. "The current, alarming trend of diminishing resources, reduced workforce and impaired capacity to maintain public health programs pose major hurdles for local agencies, with consequences that will be felt well into the future," said Dr. Rachel Willard of the University of California.

To view an article on the impact of the 2008-2010 economic recession on local health departments, one on a local health department that is providing only essential services, and one on enhancing public health value in an era of declining resources, click here.

Requiring prescription for pseudoephedrine is 'silver bullet' against meth, drug officials say; some lawmakers disagree

By Tara Kaprowy
Kentucky Health News

If Kentucky wants to arm itself with a "silver bullet" against methamphetamine, it needs to make pseudoephedrine available only prescription. That was the advice of top drug officials in Mississippi and Oklahoma, who testified before lawmakers Thursday. Opponents of the idea did not testify but legislators on their side had their say.

"This is a high-stakes cat and mouse game which has damaging results if we don't win," said Darryl Weaver, director of the Oklahoma Bureau of Narcotics. "The bottom line is: Do you want to track meth labs or do you want to eliminate meth labs?"

Marshall Fisher, director of the Mississippi Bureau of Narcotics agreed: "There is a silver bullet and the silver bullet wasn't tracking it; it wasn't limiting the amount. Weaver and Fisher testified at the request of the Senate and House Judiciary Committees, whose members heard exclusively from officials who support prescription-only policy.

Several related bills are on the table this year, including measures by state Rep. Linda Belcher, D-Shepherdsville, and state Sen. Tom Jensen, R-London, that would reclassify the drug to make it prescription-only. State Rep. Brent Yonts, D-Greenville, would apply the prescription rule only to people who have been convicted of a meth-related charge. The bill sponsored by Sen. Jerry Rhoads, D-Madisonville, would prohibit such offenders from buying the drug for five years.

Mississippi passed a prescription-only law 18 months ago and has seen a 67 percent drop in the number of its meth labs, Fisher said. Weaver said he is pushing for a prescription-only law in Oklahoma since its meth problem continues to grow, despite efforts to electronically track and limit sales of the drug.

All efforts have just been temporary fixes in Oklahoma, Weaver said, since they resulted in "smurfing," in which meth cooks pay others to buy pseudoephedrine for them. The same thing happened when that state instituted a drug registry, in which people who had been convicted of a meth-related crime were prohibited from buying pseudoephedrine without a prescription. The problem, Weaver said, is the tracking and registry "formed more of a conspirator group," where cooks were approaching the homeless and the previously uninvolved African American community to buy the drug for them.

Lt. Col. Joe Williams, executive director of the Appalachia High Intensity Drug Trafficking Area, said smurfing is a big problem in Kentucky too, and MethCheck, the tracking system in place now, does little good in helping law enforcement find meth labs. Meth labs "find us for the most part, we don't find them," he said. "Once we find a meth lab, we'll use the electronic tracking system and use that to trace back."

That runs counter to what Maj. Tony King of the Jefferson County Sheriff's Office said Monday on KET's Kentucky Tonight. In order for pseudoephedrine to be made available only by prescription, it must be reclassified as a legend drug. But those drugs are not tracked by MethCheck, which instantly tracks purchases at the point of sale, but by KASPER, the state's slower system for monitoring prescription drug abuse. "We will lose the ability to track these people and we will lose the ability to track these labs," he said.

Several lawmakers asked whether making pseudoephedrine available only by prescription would just result in doctor shopping and cold and allergy clinics popping up like so-called prescription pill mills. Williams said smurfers just won't take that risk. "It's very hard to fake snot in your nose," he said. "It's pretty easy to fake back pain."

Belcher's proposal would exempt pills in gel-cap format from the prescription rule, which prompted Rep. Sarah Beth Gregory, R-Monticello, to ask if that wouldn't eventually become a problem. Yonts pointed out that the U.S. Drug Enforcement Administration has said pseudoephedrine is "readily extractable" from gel caps. Weaver said he's "yet to see one lab that has been made with gel caps and liquids," he said, adding, "We have to find a balance between intrusion of government and what we need to stop the problem."

But it's that intrusion that has Yonts calling his measure the "middle ground," saying it protects "the soccer moms and Walmart moms" from having to constantly take their kids to the doctor but punishes the offenders. And while officials say only 15 cold medicines would be affected by requiring a prescription, leaving 137 other options, Yonts said medicines containing pseudoephedrine account for 63 percent of sales.

Williams said the average meth lab costs $2,100 in law enforcement, including manpower, overtime, equipment and waste disposal. With 1,146 labs found in Kentucky in 2011, that translates to $2.4 million. Sen. Robert Stivers, R-Manchester, said the problem is "a much larger cost to the taxpayers" since "the majority of these people are probably indigent care and the taxpayer is paying the bill for this."

Whatever the cost, Rep. Johnny Bell, D-Glasgow, called the issue "the most important" of the session. "I hope that we'll step forward and think about the human life and the impact it's having."

Representatives of the Consumer Healthcare Products Association said after the meeting that Pat Davis, identified as a mother of six from northern Kentucky, signed up to speak at the meeting but did not get to. She said she would have spoken about a prescription bill's "impact on consumers and parents, yet the committee was forced to watch videos of news reports and slides that have been seen several times already. It is apparent that the voices of consumers and parents aren’t important to the people running this process."

Federal cuts, financial instability and competition leave many rural hospitals fearing the future

Many rural hospitals could be forced to close because of cuts to the Critical Access Program and the fact that, according to the National Rural Health Association, , 41 percent of critical-care hospitals are losing money, reports Jenny Gold of Kaiser Health News. This would be devastating to many rural communities, with a great impact felt by low-income and elderly residents. "A small hospital is often one of the biggest employers in a rural town, and closures 'can have an outsized economic impact,'" Eric Zimmerman, a health care lawyer and Washington lobbyist, told Gold.

More than 1,300 U.S. hospitals and nearly one in four acute-care facilities are designated as "critical access," giving them slightly higher Medicare and Medicaid reimbursements in return for limits on care they can provide. Many such hospitals like Hood Memorial, about an hour outside New Orleans, are dealing with uninsured patients, inability to collect payments from patients, and fewer funds from federal and state agencies, Gold reports. Many of these hospitals "tend to provide lower quality care" and are "less financially efficient than other facilities, according to a 2010 study published in the Journal of Health Politics, Policy and Law. Hood, for example, had $700,000 in losses last year despite the higher reimbursements. "It's a lot of variables, and all of them right now are working against us," CEO Hoppie Jones told Gold.

To prevent closures of rural hospitals and ensure "Americans in in isolated areas would still have access to health care," the federal government started the critical access program in 1997. To qualify, hospitals had to have 25 or fewer beds and be at least 35 miles away from another facility. However, states could waive the distance requirement, and many did, leaving hospitals like Hood with at least four other competing hospitals "within a 26 mile radius," Gold reports.

Thursday, Nov. 17, will be first National Rural Health Day

Nov. 17, 2011 will be the first annual National Rural Health Day sponsored by the National Organization of State Offices of Rural Health. The goals of the event are to highlight rural communities as wonderful places to live and work, increase awareness of rural health-related issues and promote the roles of state rural-health offices in addressing those issues.

On Nov. 17, the organization will host a series of free webinars in conjunction with the observance. To learn more about the webinars, click here. The group also has a series of free tools newspapers can use to promote the event. (Read more) The Center for Rural Health is hosting a photo contest to promote the event. To find your state's rural health office, click here.

New Florida laws helping stem flow of pills, but loopholes remain and trade is shifting to other states

Though pill mills continue to be a big problem in Florida, where lax laws have fueled Kentucky's prescription pill trade, there is evidence that the tides are slowly turning in the Sunshine State. "Registered pain clinics in Florida have dropped from 930 last year to 736 now as the state begin to crack down," reports Laura Ungar of The Courier-Journal in the second installment of a special report on prescription drug abuse. (C-J photo by Kylene Lloyd: Broward County Detective Brann Redl)

A Florida law that took effect in July increases penalties for physicians who over-prescribe, tightens rules for prescriptions and pain-treatment regimens, and decreases the amount of time dispensers have to report the sale of prescription drugs into an electronic monitoring system that started Sept. 1.

The worry now is pill mill operators may just move to surrounding states. Georgia has seen a surge in clinics. "Each community outside of Atlanta is seeing an increased problem," said John Horn, first assistant U.S. attorney in Georgia, which has no electronic prescription-drug monitoring program. Some Kentucky addicts are heading to Ohio, Tennessee or West Virginia to get their pills, though now an interstate task force is helping to curb those efforts. (Read more)

There is also fear that the new law in Florida contains loopholes. "For example, board-certified pain specialists, such as anesthesiologists and surgeons, are exempt from pain-clinic registration and inspections," Ungar reports. The law also "doesn't require drug testing for patients."

But there are efforts on the national level by the U.S. Drug Enforcement Agency to stem the problem. Operation Pill Nation, launched in 2010, resulted in the DEA and other agencies making 340 undercover buys from more than 60 doctors working in more than 40 clinics in the first nine months of the operation. "The first arrests came in late February, when 22 people were picked up in one day," Ungar reports. A Florida strike force that started in March resulted in 937 arrests, including 17 doctors, and the confiscation of more than 250,000 pills.

There is also evidence that state drug monitoring systems work because they are a "major deterrent to doctor-shopping and a main reason Kentuckians go to Florida for drugs," Ungar reports.(Read more)

Despite new laws, Florida still fuels 'pill pipeline' to Kentucky

If you thought Florida's recent moves to stop the "pill pipeline" to Kentucky have worked, think again. "Cash-only clinics continue to operate throughout the Sunshine State, with doctors indiscriminately doling out prescriptions for such drugs as oxycodone and Xanax, often after little more than a cursory physical examination or a glance at an old MRI scan," Laura Ungar of The Courier-Journal reports from Fort Lauderdale. (C-J photo by Kylene Lloyd: Florida addict Bree Saghy shoots up crushed oxycodone, for which she has a prescription)

Florida has "new laws that forbid felons from owning clinics, strengthen penalties for doctors who over-prescribe painkillers and tighten rules for prescriptions and pain-treatment regimens," Ungar writes for the Louisville newspaper. "But anti-drug activists and officials worry they don’t go far enough, that pain-clinic operators, for example, will continue to charge hundreds of dollars in fees to customers or send them to associated pharmacies that may give the clinics a share of the profits — and Kentucky will keep paying the price. Local law enforcement and drug-policy officials estimate that 60 percent of Kentucky’s illicit pills come from Florida. . . . Police in Hazard, Ky., say there are neighborhoods in that Appalachian city where nearly every other household includes an addict or a dealer, and Deputy Chief Joseph Engle lays the blame squarely on Florida’s pain clinics, calling the doctors who allegedly fuel the trade 'murderers.'"

And the pills continue to be easy to get. The first step is usually to get an MRI, which gives the doctor an excuse to write a prescription. "Some bring old scans, try to pass off other people's as their own or get new ones at Florida imaging centers that sometimes have referral arrangements with clinics," Ungar reports. One recovering addict said he paid $500 to get an MRI and gave it to a doctor in Boca Raton. "You go down there, and they act so professional. But you are both knowing that nothing's wrong with you," he said.

The result has had a big effect on the Appalachian region of Kentucky. Dr. John Robert Morgan, who has worked in several Eastern Kentucky hospitals, spoke of one overdose patient "who came in with a bottle containing more than 200 oxycodone pills prescribed by an obstetrician/gynecologist in Miami. However, the patient was a man," Ungar reports.

The C-J devotes most of its Sunday front page and four inside pages to the issue. To read it and view videos online, click here. UPDATE, Oct. 17: A second installment takes most of the front plus two pages inside; there's also an interactive map and video narrative from Ungar; click here for the whole series.

Health exchange could cost up to $34 million in Ohio; Kentucky still biding its time -- until after the election?

As 27 states, including Kentucky, bide their time in setting up a health care exchange — a key component of the federal health-reform law — Ohio officials have said setting one up in their state will cost $19 million to $34 million.

The undertaking could cost $8 million a year just for staff salaries, with 170 employees needed to run the exchange, reports Cliff Peale of the Cincinnati Enquirer. Marketing could cost $5 million a year, said a health-care consultant at Milliman Inc., an actuarial and consulting firm.

"Ideally, we want to see Obamacare repealed," said Susan Verble, deputy chief of staff for Ohio Lt. Gov. Mary Taylor, who also directs the Ohio Department of Insurance. "Whether it's a state or federal-run exchange, it's going to be costly for taxpayers."

Starting in January 2014, "the law will require all Americans to buy health insurance or pay a penalty and require companies with more than 50 workers to offer benefits or pay a penalty," Peale reports. Ohio and Kentucky have each received $1 million from the federal government to research how to start an exchange.

Kentucky has not decided whether it will operate an exchange. Officials with the Cabinet for Health and Family Services said last month Kentucky is still awaiting guidance from the federal government, but didn't respond directly when asked if the impending election for governor was also a factor. (Read more)

Tonight, acting Gov. Earl Ray Tomblin of West Virginia narrowly won a special election for the remainder of an unexpired term, after losing a big lead. The final television commercial from the Republican Governors Association was an attack that Kentucky Gov. Steve Beshear may be trying to avoid: A link between a Democratic governor and the unpopular Democratic president's health-care law, passed with only Democratic votes. --Al Cross, Institute for Rural Journalism and Community Issues

Some worry that patient care will get shortchanged as Kentucky Medicaid moves to managed care

While moving Kentucky's Medicaid patients to managed care for will likely reduce costs to the taxpayers, patient care shouldn't be shortchaged in the effort to save a buck, Deb McGrath writes in an op-ed piece in The Courier-Journal.

"It is critical for quality patient care to always remain a priority," writes McGrath, executive director of the Epilepsy Foundation of Kentuckiana. "All citizens, including the 540,000 Kentuckians under the new managed care plans, deserve access to the best possible care recommended by their doctors."

McGrath is concerned about the "fail first" policy, also known as step therapy. "In this practice, the insurer will initially cover only the least costly medication in any drug class, forcing doctors to prescribe these medications first," she writes. "This is problematic because many times there are different medications that the physician feels would be the most effective treatment."

The policy can adversely affect Kentucky's 90,000 patients who have epilepsy, a disease that comprises 40 different seizure types and epileptic syndromes. "Fail first is not something a person with epilepsy wants to hear, especially when this policy can compromise their well-being and even their life," McGrath writes. "I urge Gov. Steve Beshear, the Cabinet for Health and Family Services, our state legislators and the new managed care organizations to keep patient care in mind as they get ready to implement this new system on Nov. 1." (Read more)