Lawrence call center expected to add positions to handle insurance exchange calls.
Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall. Kansas is one of the four states.
Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A U.S. Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa, Fla. — all states with Republican leaders who oppose the law.
A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said.
Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government. The other states are relying entirely on the federal government.
Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.
The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government.
The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion.
States running their own marketplaces will have their own call centers.
The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and “other relevant programs,” the award announcement stated.
With the filing deadline approaching, the nation’s largest tax preparation company is letting its customers know how they are likely to be affected by the Affordable Care Act.
“After the ACA was upheld by the Supreme Court in 2011, we did some focus groups and some surveys to try and measure the public’s understanding of what all is in the ACA,” said Meg Sutton, senior advisor for tax and health care services at H&R Block. “It became pretty clear that there needed to be a process for educating our clients.”
Sutton called the 2010 federal health reform law the “biggest tax-code change in the past 20 years.”
The company’s tax preparers, she said, have been calling their customers’ attention to the ACA’s penalties for not having health insurance and to the subsidies that will be available to low- and modest-income families.
The information also is available on an H&R Block website.
“Client reaction has been very positive,” Sutton said.
The company’s surveys, she said, had found that 77 percent of its clientele didn’t realize their 2013 tax returns would be used to determine their eligibility for health insurance subsidies and that 44 percent of those between ages 18 and 34 were unaware of the penalties for being uninsured.
Sutton said the company’s tax preparers do not tell their customers to buy - or not to buy – health insurance. Instead, she said, customers are “informed of their options” based on the information in their 2013 tax returns.
The ACA’s mandate that almost all Americans either have health insurance or pay a penalty takes effect Jan. 1, 2014.
Marvin Lawton has been a tax preparer at the H&R Block office in Topeka for the past eight years.
“I’ve found there to be quite a cross section in the way people react – all the way from being OK with it to being dismayed by it,” he said. “Some are OK with it because they already have insurance and won’t be affected by it, some are bewildered over how they’re going to afford it and some wonder why they have to pay a penalty if everybody in their family is healthy."
Most of his customers with little or no health insurance have seemed pleased to hear about the subsidies, he said.
“I’ve had a lot of people who used to have insurance through their job but ended up getting laid off in the past year,” he said. “They know how expensive health insurance is. So when I tell them about penalties, they say ‘But I can’t afford it.’ Then, when I tell them about the subsidies and how they’ll be able to buy it through the exchange and be part of a larger pool, they’re OK with it. They say they’re OK with it if it’s affordable. And I say that’s the intent, that’s why it’s called the Affordable Care Act.”
H&R Block customers have the option of signing up for email alerts on changes in the new health reform law.
Sutton said, H&R Block appears to be the only national tax preparation firm helping its customers predict the law’s effect on their 2014 taxes.
Surveys have shown that about 60 percent of the nation’s taxpayers use tax preparation companies. H&R Block accounts for almost 20 percent of the tax-preparation market.
Kansas Health Consumer Coalition Executive Director Anna Lambertson said she welcomed the company’s initiative.
“I think it’s great,” Lambertson said. “I give them high marks.”
The coalition, she said, has been looking for ways to launch a similar informational campaign in Kansas.
“We can’t do it alone,” she said. “And H&R Block can’t do it alone. It’s going to take everybody getting involved.”
Sheldon Weisgrau, a spokesman for the Health Reform Resource Project, also praised the company.
“I assume they’re hoping this will lead to more people coming to them to have their taxes done,” he said. “But that’s fine. Anytime you’ve got someone providing accurate information it’s a positive.
Weisgrau said federal officials have announced plans for launching a major outreach campaign in June.
“They don’t want to start too early, which makes sense,” he said. “The exchange won’t be up and running until October.”
Mary McBain, chief executive of the Kansas Society of Certified Public Accountants CEO said the H&R Block initiative had not gone unnoticed.
“The major accounting firms have definitely been ramping up for this,” she said. “Some of the bigger firms have hired people just to work on ACA – that’s all they do.”
MacBain said her organization was committed to providing its members with accurate information about the law.
“All of us, I think, need to take a deep breath and not get caught up in all the emotion that’s comes with health care reform,” she said. “We need to be informed because, frankly, there’s a lot of misinformation out there.”
→ Find more information on health insurance exchanges and other health reform topics at khi.org/healthreform.
After months of trying to dance around the politically charged issue, the administration of Gov. Sam Brownback has openly acknowledged that the $139 million Medicaid enrollment system that it is building will be interconnected with the online health insurance exchange required by the Affordable Care Act, and that the system will be ready to go by the Oct. 1 federal deadline.
“It's just a connectivity kind of a thing,” said Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, which is spearheading the project to overhaul the 26-year-old, paper-based system to a modern online one.
“I certainly appreciate the concerns that are tied to the political angst, but this program was well on its way when I came on board and my job is to make sure it gets completed successfully,” he said.
Entangled with the exchange
Overhauling the state’s antiquated Medicaid enrollment system has been in the works since at least 2009, when the project was called K-MED.
The project stalled briefly in August 2011, when Brownback returned a $31.5 million federal grant, most of which had been earmarked for developing the state’s new Medicaid enrollment system. Brownback said he was returning the grant because it was tied to the Affordable Care Act — which he he had pledged he would not implement prior to the U.S. Supreme Court ruling on the law, and later until after the 2012 federal elections.
Then that same month, administration officials announced a new contract with Accenture to develop the Kansas Eligibility and Enforcement System (KEES), using $118 million in federal funds to pay for the $139 million projected cost. K-MED became KEES.
A key condition of the federal funding was that the KEES system would have to be “interoperable” with the coming health insurance exchange — an online marketplace scheduled to launch Oct. 1 where consumers can compare and buy coverage that will begin Jan. 1, 2014.
In Kansas and the 25 other states that elected not to run their own health insurance exchanges, the federal government will build and operate them.
Moser said interoperability of KEES and the exchange means that — for consumers — there will be a single entry point for enrolling in private health insurance or in Medicaid, the state-federal health care program for low-income, elderly and disabled persons. Medicaid in Kansas is known as KanCare.
“You enter in some information, most of it is going to be yes/no. If you're eligible for Medicaid then it would pop up the KEES patient portal,” Moser said. “If it shows that your income level is such that you don't qualify for Medicaid…it's going to push your information over to the federal exchange. So those two systems literally will be handing back and forth inquiries.”
Moser said the fact KEES would interface with the insurance exchange was no different than integration with other federal computer systems, such as Homeland Security or the Internal Revenue Service.
“It doesn't really have that significant of an implication in my mind. But then again, I'm a physician and a little bit more patient-centered and look at the convenience factor. If that person is in a hospital setting and I think they need admitted, but they're worried about the cost because they don't have coverage, I'd like to be able to determine at that point in time 'Are they eligible for coverage' and use that as leverage to get them in to the hospital,” Moser said.
Is the whirl of hospital revolving doors slowing?
Federal health officials are now reporting that the rate of preventable and costly hospital readmissions is down for the first time in more than five years, which meant about 70,000 fewer hospital returns nationally in 2012 for the Medicare program alone.
With a strong push from the federal health reform law, scores of medical and social service workers around Kansas — like thousands of their counterparts in other states — are working together on projects that officials say show promise for reducing avoidable readmissions.
If they succeed, hospitals could be spared some of the Affordable Care Act penalties they face in the form of reduced Medicare payments and federal health care spending could be trimmed $8.2 billion by 2019, if projections from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) prove accurate.
Starting in October 2012, almost 30 of the 46 non-exempt Kansas hospitals were punished for relatively high readmission rates in the first year of the ACA program, according to information from CMS compiled by Kaiser Health News, a partner of KHI News Service.
Because of the potential financial sting attached, nobody wants to be on that penalty list when it’s redrawn for this year, especially since last year’s maximum penalty of a 1 percent reduction will grow to a maximum 2 percent and then 3 percent for 2014.
“Almost every hospital is looking at this, because they stand to gain or lose,” said Ken Mishler, chief executive of the Kansas Foundation for Medical Care, a Topeka-based, non-profit organization that is the federal government’s sole designated contractor in Kansas for improving health care quality. In federal parlance, the foundation is known as a Quality Improvement Organization or QIO.
Mishler’s group was directly involved with organizing projects in four locations - Hays, Topeka, Kansas City and Wichita – but there are others underway, too, including one by the Kansas Healthcare Collaborative, a 2008 creation of the Kansas Hospital Association and the Kansas Medical Society.
There is evidence the various efforts, some of which predate the ACA, may be working. The readmission rate in Kansas was already lower than the national average, but recent numbers show even that somewhat lower rate has dropped.
According to the Kansas Foundation for Medical Care there were 49.4 per 1,000 Medicare fee-for-service patients readmitted to Kansas hospitals within 30 days in 2011 versus 52.5 in 2010. That compares favorably to the national average of 56.8 per 1,000 in 2011 and 58.2 per 1,000 in 2010. Foundation officials say the ultimate goal is a 20 percent reduction.
The efforts to make that happen in Kansas vary place to place but among the things they have in common is the involvement of multiple types of medical and social service providers or agencies, not just hospitals.
The reason for that, experts say, is that one of the best ways to reduce readmissions is to make sure that patients get proper follow-up care or attention after they are discharged whether they leave the hospital to live alone at home - where they may receive limited assistance from a variety of outside sources - or a skilled nursing facility where they get more-or-less 24-hour attention.
‘A community problem’
“It’s not just a hospital problem. It’s a community problem and you have to get all the providers together. It’s not easy work. It’s hard work,” said Laura Sanchez, the project director for the Kansas Foundation for Medical Care.
A bill that would roll back a requirement that Kansas utility companies increase their use of renewable energy has been saved from the legislative bell.
The House failed last week to pass the bill — HB 2241 — as lawmakers worked to meet a mid-session deadline for moving legislation from one house to another. Instead, members voted 63-59 to send the measure back to committee.
Ordinarily, that would have ended consideration of the bill. However, House leaders quickly revived it by sending it to the Committee on Appropriations, where bills may remain alive until the end of the session.
The fact that the House leadership re-routed the bill indicated supporters were gearing up for another attempt to pass it.
Current law requires Kansas utilities to obtain 20 percent of their peak-demand power from renewable sources like wind and solar by 2020. The House bill would roll back that requirement to 15 percent, a benchmark state utilities have already all but met.
Opponents of the bill say passing it could send a negative signal to the wind energy industry strong enough to end a building boom that has created 13,000 jobs and pumped more than $7 billion into the Kansas economy since 2001.
“Why would we want to do that,” asked Rep. John Doll of Garden City. “It’s like stopping at the end of the race so to speak.”
Doll is one of several Republicans questioning the wisdom of rolling back regulations that supporters say have benefited the state economically while having no apparent impact on electric rates.
Opponents of the regulation point to studies by conservative think tanks that show renewable standards have contributed to rate increases in other states. But the fact they haven’t substantially increased rates in Kansas has weakened the case for the bill.
“It seems like that message isn’t true,” said Rep. Ronald Ryckman, Sr., a Republican from Meade.
The Kansas Corporation Commission tracks the impact of renewable standards on rates. In 2012, wind energy accounted for 0.72 cents of the average retail electric rate of 9.2 cents per kilowatt hour, according to the commission’s most recent report.
Despite that, influential national conservative organizations are pushing for passage of the roll-back bill. They include the American Legislative Exchange Council (ALEC) and American’s for Tax Reform, the organization headed by Grover Norquist.
In a letter sent last week to Kansas legislators, Norquist called renewable energy standards a “command and control policy” that forces utilities to utilize “more costly and less reliable” energy. He said while the roll-back bill was a good start, “Ultimately, it is imperative that lawmakers repeal the mandate all together.”
Kimi Narita, an energy fellow with the National Resources Defense Council, devoted her latest blog to the renewable battle in Kansas. In it, she cited “giant forces” behind the Kansas effort, which she calls “a nation-wide attack” on renewable standards that are on the books in 29 states and the District of Columbia.
“Kansas is one of the priority states on their list, and repealing the Kansas RPS represented a critical first step in their momentum building strategy,” Narta wrote.
More often than not, many of the groups pushing for a roll-back of the renewable standards are aligned with Republican Gov. Sam Brownback on issues. The renewable standards are an exception. Several legislators and lobbyists said the governor’s quietly stated concerns about weakening the standards led to the defeat last week of a Senate bill that would have given utilities more time to meet them. The bill — SB 82 — was defeated 27-13.
The Lawrence-Douglas County Health Department announced today that it has partnered with the University of Kansas to form the state's first "Academic Health Department."
Among other things, the research skills of the KU Work Group on Community Health and Development will be utilized to better gauge effectiveness of services and strategies deployed by the health department.
Dan Partridge, the health department's director, said the Academic Health Department would play a pivotal role in helping his agency evaluate and document the successes and failures of policies and systems that aim to improve community health.
“A major focus will be to answer the question: How well are community-based efforts working to improve health,” said Partridge. “We hope the answers will help inform future decisions promoting the health and vitality of Douglas County.”
The Academic Health Department will also function like a teaching hospital for KU students in applied behavioral psychology, the academic home of the KU Work Group, said Vicki Collie-Akers, who leads the group's research efforts.
“We hope to ultimately create a shared research agenda with the health department...to merge our goals with theirs,” said Collie-Akers, who will have an office at the health department.
The health agency and the KU work group already have a history of working together — most recently in facilitating a Comprehensive Community Health Assessment as part of the agency's work toward accreditation.
Among the short-term goals of the Academic Health Department will be implementation and evaluation of the county's first Community Health Plan, another component of the health department's work toward accreditation.
It's difficult to gauge how many Academic Health Departments there are in the U.S., said Kathleen Amos, who leads the AHD Learning Community for the Public Health Foundation in Washington, D.C. There are at least 36, from a list she's informally compiled, but she said that is likely far fewer than there actually are.
She pointed to the most recent National Profile of Local Health Departments (pages 71 and 72), which indicates that about 20 percent of health departments nationwide have worked with a four-year academic institution on program evaluation, and about 35 percent have some sort of written agreement with a university.
A Wichita lawmaker has introduced a bill that would require cities that fluoridate the water to notify users "that the latest science confirms that ingested fluoride lowers the I.Q. in children."
House Bill 2372 was offered by Rep. Steve Brunk, a Republican, who said he introduced the bill on behalf of Mark Gietzen, a conservative GOP activist and anti-abortion lobbyist also of Wichita.
But Brunk said he did not expect the bill to advance and that he had no interest in it himself.
"That was a constituent request," Brunk said. "As a courtesy, I gave him a bill introduction and told him that was as far as it goes. I'm not his champion of the cause," he said.
"I'm not aware of any interest in this bill at all (among fellow legislators). I'd be surprised if the (committee) chairman gives him a hearing."
Fluoridation has long been accepted by public health experts in the U.S. and elsewhere as an effective means to combat tooth decay, especially in children. Its use has been widespread among public water suppliers in the U.S. since the 1960s. According to the federal Centers for Disease Control and Prevention about 74 percent of the nation relies on fluoridated water supplies. The CDC has linked public fluoridation with an increase in the incidence of dental fluorisis, a condition that can cause tooth enamel to appear streaked but is not generally considered harmful to health.
Most research on the subject has shown municipal water fluoridation to be a safe and and effective practice. There are a few scientists who say their studies suggest otherwise, and that their findings have been marginalized by the broader scientific community.
Gietzen told KHI News Service he hoped to take advantage of the recent publicity surrounding Wichita's citywide vote on whether to fluoridate its public drinking water. Voters there rejected fluoridation, just as they did previously in 1978 and 1964. Wichita is among the few larger American cities that do not fluoridate public water supplies. The cities of Topeka, Lawrence, Manhattan and dozens of others in Kansas do add the CDC-recommended amount of fluoride to driking water. Many rural water districts also provide fluoridated water to their customers.
"The momentum of the Wichita fluoride debate (is) something we want to capitalize on," Gietzen said. "With everything — asbestos, lead, thalidomide, the drug we once thought was so good — when more modern science shows you that what you thought in the past was good and now you know it's not good, you need to put the brakes on it and stop harming people."
Gietzen cited a a 2012 study co-authored by a researcher at the Harvard School of Public Health that showed children in areas with high naturally occurring fluoride have significantly lower I.Q. scores than children in low-fluoride areas. He said it was that study that convinced him to vote against fluoridating Wichita's water.
"Eight months ago I didn't know how I was going to vote on the Wichita fluoride debate. I couldn't even spell fluoride, truth be known," Gietzen said. "If something opened your eyes and you realized you have knowledge of something other people are being harmed by and they didn't even know it, wouldn't you feel the obligation to at least let them know?"
The study by the Harvard researcher, however, mostly considered the effects of high levels of fluoride on brain development among children in China because that's where there are significant numbers of people exposed to high levels of fluoride, often from well water and not as the result of municipal fluoridation. The study's authors noted that it was difficult to find study subjects in other industrialized countries because children there aren't exposed to high fluoride levels in the water "even when fluoride is added to water supplies as a public health measure to reduce tooth decay."
Officials at the Kansas Health Foundation announced Friday they will issue grants this year to support the formation and work of Food Policy Councils across the state.
According to a foundation request for proposal, it will accept applicantions for “capacity building” grants of $10,000 and policy implementation grants of $40,000 that will be available through 2016.
Only local, county or state government agencies are eligible to apply for the grants, which the foundation said are designed to increase access to and consumption of healthy foods.
Grant recipients would be expected to contribute staffing or some other support to the effort.
The RFP lists several activities as examples of objectives the foundation would like to see Food Policy Councils pursue. Those include working with school districts to restrict student access to unhealthy foods and collaborating with local officials to increase public transportation options for people who have limited access to supermarkets or farmers markets. Helping local governments establish policies that promote locally grown foods and lead to the establishment of community gardens were among the other sample objectives listed in the RFP.
Additional information on the Food Policy Council grants and an online application are available at the foundation’s website, kansashealth.org.
The Kansas Health Foundation established the Kansas Health Institute with a multi-year grant and continues to provide most of the institute’s funding.
Weeks before the flu season typically peaks, nearly half of Kansas' county health departments report depleted or low supplies of influenza vaccines.
The Kansas Association of Local Health Departments surveyed its 99 members this week, asking which had depleted or nearly depleted their supply of flu vaccine. Among the 43 that replied:
• 21 are completely out,
• 17 are "low on supply," and
• Five were able to restock after running out once or more.
Officials at the Lawrence-Douglas County Health Department reported having adequate vaccine supply.
Michelle Ponce, the association's executive director, said in many rural communities, county health departments are the primary place people get flu shots because other health care providers and pharmacies tend to be fewer and far between.
"In many rural areas, you're not going to have a Walgreens (pharmacy) in town that you can go to (for a flu shot). Many private providers do give flu shots, but all health departments do."
The Sedgwick County health department was the sole exception. It didn't provide the vaccine this year, "based on the abundance of other providers offering them in the community," Ponce said.
Early vaccine shortage
In the survey, many health department officials indicated two factors were involved in the shortage: Fewer doses were ordered this year after many went unused last year and this season there was higher early demand.
"We were out by December 31st," wrote Kandy Dowell of Elk County. "Last year I ordered the usual amount and had to waste 120 doses, so I didn’t order as much this year."
"Pawnee County Health Department has given over 1,500 doses already. This is about 550 more doses than last year," Mary Beth Herrmann, the administrator, wrote, indicating she was low on all but one type of flu vaccine.
Marcia Hansen, Republic County administrator, wrote: "We have reordered numerous times and have given nearly twice the amount (of shots) we have in previous years...We have had a number of people come from neighboring counties during the past weeks."
In Wabaunsee County, administrator Janet Wertzberger wrote: "We ran out of flu vaccine about the 15th of December and did not try to order more because we did not want vaccine going to waste again this year... We did not have requests for vaccines until the national media started talking about the flu as an epidemic."
More severe flu season so far
This year's flu season so far has been more severe than in 2012, said Charlie Hunt, state epidemiologist at the Kansas Department of Health and Environment. But that doesn't necessarily indicate how the rest of the year will go, he said.
"Last year's levels were nowhere near what we've seen so far this year," Hunt said. "We don't know yet what the peak is going to be for this season...February is pretty typical over the last 10 years. We've seen a peak in October during the pandemic of 2009 and 2010, but having it start to increase in December is a little odd."
Hunt said the number of cases could go up or down.
"It will depend on how many people are vaccinated, and how many people are listening to messages about staying home when they're sick, covering their coughs and sneezes, washing hands," he said. "All those are factors."
The state health department earlier this month stopped analyzing HIV tests for many of the state's medium and small counties and also stopped providing rapid or oral test kits, which is creating a new burden for cash-strapped health departments and creating some uncertainty whether they can continue testing for the disease in some rural locations around Kansas.
Compounding the problem, some local department heads said, was the short notice they received that the services previously provided free to them by the state were being terminated.
Notification letters from the Kansas Department of Health and Environment went out in late November, they said, giving them only about five weeks, including the holidays, to make alternate arrangements in time for Jan. 1, when the new policy kicked in.
"It's another nail," said Julia Hulsey, director of the Reno County Health Department in Hutchinson.
Kansas routinely ranks low nationally in its support for public health agencies.
New cost for patients
Hulsey said her department was able to contract with a laboratory in Wichita that agreed to provide the testing supplies for free (though it will charge for the lab work) and so her agency plans to continue the tests but will start charging patients for them probably by Feb. 1, once she has a clear picture of her agency's new, added costs.
"I don't have that whole cost figured out yet," Hulsey said, "but, of course, it will be more than KDHE because they didn't charge for it."
She said her goal would be to price the tests as low as possible to not discourage people from getting them. She said the department historically has performed about 220 tests a year.
Dan Partridge, director of the Lawrence-Douglas County Health Department, said Lawrence Memorial Hospital agreed to help with the testing after KDHE withdrew the services, so it will only cost his agency about $9,000 a year to continue the testing instead of about $18,000. But he said the new obligation signals another state retreat from support for local health departments.
Urged to continue
State officials, in their November letter, urged the local departments to try to continue the services on their own.
KDHE "would like to encourage your agency to continue to provide HIV testing to clients requesting an HIV test, especially those reporting high-risk behaviors," the letter stated. "However, any test conducted at your agency beginning January 1, 2013, and continuing thereafter will need to be paid for by either your agency or by the client through insurance, public assistance programs, or out-of-pocket."
But a spokesperson for the state's local health departments said it would be difficult or impossible for some smaller departments to pay for the tests on their own.
"I suspect there will be some health departments in some areas that won't be able to find a workaround like Douglas County," said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. "I couldn't give you a firm number, but in some of those rural areas they may not have another option for testing."
The state’s letter also included some cost-comparison information to help the local departments shop for testing materials, lab work and other necessities of the program.
Hulsey in Reno County said she ended up considering four or five outside laboratories between the time she got the letter and Jan. 1 when the state assistance stopped.
"We got very short notice on this," she said. "And then having to go negotiate for ourselves...you never know if you're getting the best price."
State officials said they had to reduce the services because of cutbacks in a federal testing program administered by the Centers for Disease Control and Prevention that has been reconfigured to focus on areas where the incidence of HIV/AIDS is greatest.
In the past, according to state officials, 40 local health departments received the free services. That number has been trimmed to 10, according to Ralph Wilmoth, director of the HIV/AIDS program at KDHE. The 10 county health departments that will continue to get the aid include Johnson, Sedgwick, Wyandotte and Shawnee, the state’s most heavily populated, and also Crawford, Pratt, Riley, Saline, Thomas and Trego counties.
The state also will provide the testing services to various organizations other than health departments in about a dozen counties. For example, in Douglas County the services will be continued for the Douglas County Aids Project, a non-profit group. In Reno County, the services will continue for the state prison in Hutchinson.
Wilmoth said the CDC made the program changes in anticipation of the full-scale implementation of the Affordable Care Act, which begins Jan. 1, 2014. Millions of Americans are expected to become newly eligible for Medicaid then and HIV testing is among the health services covered by Medicaid.
Linked to Medicaid expansion
But when the U.S. Supreme Court ruled on the health reform law, it concluded that each state had the option to not expand its Medicaid eligibility and Gov. Sam Brownback nor the Kansas Legislature have yet determined whether Kansas will broaden access to its program, which is known as KanCare.
A recent survey has found that half of Kansas adults gamble about once a month and that almost one in 12 admits to having bet more than they could afford to lose.
“It’s a real problem,” said Joyce Markham, an addiction counselor and president of the Kansas Coalition on Problem Gambling. “This affects not only the gambler, it also affects family members, our friends, and our co-workers through bankruptcies, crime, domestic violence and health care costs.”
Markham said she knew of several families that had lost their farms, homes, and life savings due a father or mother’s addiction to gambling.
The survey, commissioned by the Kansas Department for Aging and Disability Services, also found that while a large majority of state’s gamblers said they did not have a gambling problem, 13 percent of the respondents said they had “been affected” by someone - spouses, family members, friends and co-workers - who did.
Conducted in October and November, the poll involved telephone calls to 1,600 randomly selected adults. Each respondent was asked 96 questions.
Buying a lottery ticket was considered a form of gambling.
“There is so much information here, it’s a bit overwhelming,” said Doug Ballou, a managing partner with Whitworth Ballou, a Kansas City marketing firm that assembled the questionnaire and oversaw the interviews.
Ballou presented an overview of the findings during a Wednesday morning meeting of the Kansas Coalition on Problem Gambling.
KDADS officials said they would use the survey to put together a policy on how best to spend the state’s problem gambling fund, which is expected to reach $8 million in the fiscal year that begins July 1.
Kansas law stipulates that 2 percent of the net revenue generated by the three state-owned casinos – Kansas Star Casino in Mulvane, Boot Hill Casino in Dodge City, Hollywood Casino in Kansas City – be spent on programs and services for people with addictive behaviors: alcoholism, drug abuse and problem gambling.
Net revenue is defined as the slot-machine and table-game income minus payouts.
In an email sent to members of the Kansas Association of Addiction Professionals last month, a KDADS official said there likely would be less money for prevention and treatment services in the proposed budget for fiscal 2014, which begins July 1, 2013. The amount of the reduction, if any, remains unclear.
Gov. Sam Brownback is expected to release his proposed budget on Jan. 16, the day after his state of the state address. The Legislature is then free to add or subtract from the the governor's spending plan.
In the current fiscal year, the 2 percent set-aside is expected to generate about $7 million, most of which is used to underwrite Medicaid-funded drug and alcohol abuse programs. KDADS treatment and prevention efforts receive about $750,000.
Several coalition members said expected the governor to propose eliminating state-funded support for prevention and treatment services.
The state’s toll-free hotline for problem gamblers (1-800-522-4700) fielded 691 calls last month.
The Brownback administration has not ruled out implementing the Medicaid expansion called for in the federal health reform law.
But a spokesman today told members of the Legislature’s Joint Committee on Health Policy Oversight that prior to making a decision administration officials want to develop their own estimate of how many Kansans are likely to sign up for the health care program and how much the expansion would cost the state.
“We’re continuing to study the issue,” said Mark Dugan, chief of staff for Lt. Gov. Jeff Colyer. “We would like to come to you with our own numbers.”
Currently, there are several competing estimates of how the expansion would affect Medicaid enrollment and the cost of the program. The latest, released earlier this month by the Kansas Health Institute indicated that approximately 240,000 additional low-income, disabled and elderly Kansans would enroll in a program that currently serves about 380,000. According to the KHI analysis, expanding Medicaid would cost the state an additional $519 million between its implementation in 2014 and 2020.
The KHI projections are higher than those in a 2010 report prepared for the now defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis done in 2010 by the Kaiser Family Foundation. However, they considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act.
The KHI News Service is an editorially independent program of KHI.
Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level — $5,900 a year for a family of four.
The ACA expansion would have a bigger impact in Kansas than many states. It would raise the eligibility threshold for all Kansans to 133 percent of FPL — $30,660 for a family of four.
Two of the four legislators who braved inclement weather to attend Thursday’s meeting of the 12-member committee made it clear that they favored the expansion.
Rep. Don Hill, a moderate Republican from Emporia, said that virtually all legislators regardless of party and ideology agree that the current health care system is broken and in need of reform to lower costs and reduce the number of people who are either uninsured and under-insured.
He said while the ACA is far from perfect, “it has some redeeming elements.” One of those, he said, is the Medicaid expansion because of its potential to extend coverage to many of the state’s 365,000 uninsured.
Citing the federal government’s promise to shoulder the cost of serving all those made eligible by the expansion for the first three years, Sen. David Haley, a Kansas City Democrat, asked, “Why can’t we cover more Kansans and why shouldn’t we?”
“I think we’re going to take a good look at it,” Dugan answered.
But, Dugan said, a factor that must be considered is whether or not the cash-strapped federal government can be counted on to keep its funding promise. After paying all of the costs of the expansion for three years, the federal government would gradually reduce its commitment until it reached 90 percent, where it would be maintained.
“He (Gov. Brownback) doesn’t have a high degree of confidence in the federal government maintaining that 90 percent commitment over the long term,” Dugan said.
Dugan said the federal government missed an opportunity to negotiate a compromise with Republican governors skeptical of the expansion when it rejected the idea of allowing states to increase eligibility to only 100 percent of FPL.
“That was an opportunity for middle ground that was lost,” he said.
Like many Kansans, Rick Cagan spent much of last weekend reading and listening to news reports about the gunman who killed 20 children and six adults at an elementary school in Newtown, Conn.
Cagan had a professional reason for learning what he could about the tragedy. He runs the National Alliance on Mental Illness-Kansas Chapter office in Topeka.
“It’s devastating,” he said. “It’s heartbreaking.”
According to initial news reports, the gunman, 20-year-old Adam Lanza, may have suffered from a personality disorder or had been diagnosed with Asperger’s, a form of autism. However, there is no indication that he had the kind of severe mental illness suffered by others responsible for mass shootings.
Jared Loughner, the man convicted of shooting former Arizona Congresswoman Gabrielle Giffords and killing six others, for instance, suffered from schizophrenia, a mental illness that causes disordered thinking and delusions.
And James Holmes, the man accused of shooting 12 people to death and wounding 58 others last summer at a movie theater in a Denver sought mental health treatment before the attack, according to multiple news reports.
Mass shootings nearly always rekindle debates about gun control and the adequacy of the nation’s mental health system. Commenting on the later, Cagan said many Kansans with mental illness are not getting the early treatment they need to avoid crises.
“More than 60 percent of the adults who have a serious mental illness are untreated,” he said, noting that in Kansas half the admissions to the state hospitals for the mentally ill involve people who’ve had no previous contact with their community’s mental health center.
In Kansas, state-hospital admissions are reserved for adults who are seriously mentally ill and have been deemed a danger to themselves or others.
“NAMI is always reluctant to jump in with some sort of comment when these kinds of incidents occur because there’s so much that we don’t know,” Cagan said, referring to the shootings. “But, still, blaming the individual only goes so far. At some point, we have to look at the overall well-being of our mental health system.”
Budget cuts in the mental health system
Kansas’ system, he said, hasn’t fared well in recent years.
“I don’t like saying this,” Cagan said, “but we’re just lucky this didn’t happen in Kansas.”
Like Kansas Gov. Sam Brownback, Bob Laszewski is a staunch opponent of the Affordable Care Act.
Despite that, the Washington, D.C. consultant said at a meeting here today that Brownback is making a mistake by refusing to partner with the federal government to run the Kansas health insurance purchasing exchange that the law requires to be operational by 2014.
“Do the partnership. That is a no-brainer,” Laszewski said to about 100 legislators, lobbyists and health care providers at a meeting sponsored by the Kansas Health Institute, the parent organization of the KHI News Service.
Laszewski, whose client list consists mostly of health insurance companies, said it’s time for opponents of the law to stop fighting it and start doing what they can to ensure that it is implemented in a way that does the least harm to the industry and consumers. One way to do that, he said, would be to implement exchanges – new online marketplaces – that encourage competition among insurance companies rather than rely on regulations to moderate increases in premiums.
“Putting the insurance exchange up doesn’t mean you support the thing (the reform law), it means you are trying to minimize the damage,” Laszewski said, predicting that premiums in the individual and small-group markets would go up no matter who runs the exchanges.
Brownback last year blocked Kansas Insurance Commissioner Sandy Praeger’s attempts to establish a state-operated exchange, returning a $31.5 million federal grant in the process. Last month, the governor told Praeger, who also is a Republican, that he would not support her efforts to partner with the federal government to operate and fund the Kansas exchange.
“Kansans feel Obamacare is an overreach by Washington and have rejected the state’s participation in this federal program," Brownback said, explaining his decision.
Praeger, who also spoke at the KHI meeting, said she would try once more before a Feb. 15 federal deadline to convince the governor and legislators that partnering on an exchange would be better than allowing the federal government to run it. Federal officials recently extended the deadline in an effort to accommodate states where governors had opposed or held out on state participation pending the outcome of the November national elections.
“There is still some opportunity for us to retain some control,” Praeger said. “Our department looks forward to working with the Legislature and the governor to see if that still is an option. The decision really rests with them.”
Praeger said partnering with the federal government would allow her department to retain authority to approve the plans marketed in the exchange and manage consumer protection efforts. She said it might also prevent federal officials from over-regulating the exchange.
The ACA calls on states to expand Medicaid eligibility to include adults earning up to 138 percent of the federal poverty level — $30,660 a year for a family of four. But the U.S. Supreme Court decision earlier this year that upheld the law also made the program expansion optional for states.
Implementing the expansion in Kansas would make more than 300,000 additional adults eligible for a program that today serves approximately 380,000 Kansans – mainly women, children, seniors in nursing homes and people with disabilities.
A KHI analysis handed out at the meeting estimated that about 240,000 additional Kansans would enroll in Medicaid if the expansion were implemented in 2014, including 122,185 adults and 117,886 children. According to the analysis, expanding Medicaid would cost the state an additional $519 million between 2014 and 2020.
The projected cost and enrollment figures in the KHI analysis are higher than those in a 2010 report prepared for the now-defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis prepared in 2010 by the Kaiser Family Foundation. But the costs projected in the KHI analysis were considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act and its implementation. The Kansas Policy Institute also projected the program’s cost through 2023.
Currently, the state’s Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and then only if they earn less than 32 percent of FPL – $5,900 a year for a family of four.
Brownback hasn’t said whether he plans to implement or recommend the expansion for Kansas. But he has said that he doubts the federal government would keep its promise to initially pay 100 percent of the cost of serving all those newly made eligible by the Medicaid expansion. Under current law, the federal commitment would be good for the first three years, drop to 95 percent in 2017 and then to 90 percent in 2020, where it would remain.
Laszewski said covering currently uninsured Kansans in Medicaid would be significantly cheaper for taxpayers than providing them with tax credits to purchase private coverage in the exchange. And he said by agreeing to the expansion, Brownback and other Republican governors might be able to get federal officials to agree to their long-standing request to convert the program to block grants to states with fewer restrictions on how the money is spent.
“Put up or shut up, that’s what I say to Republican governors,” Laszewski said. “It gives you leverage to get what you’ve always said you wanted — autonomy. Go to the Obama administration and say, ‘OK, we’ll expand Medicaid but we’re not going to do it your way.’”
The Lawrence-Douglas County Health Department will be closed for two days this week in order to finish implementation of an electronic health record system.
The clinic and staff offices will be closed from 8:30 a.m. to 1 p.m. on Dec. 4 and 5, as well as Dec. 26 while it trains staff on the new system.
Douglas County is now the fifth in the state to have its health department transition from paper health records to an electronic system. The others are Johnson, Wyandotte, Shawnee and Lyon counties, according to the Kansas Association of Local Health Departments.
Since 2009, use of electronic health records (EHRs) has been surging among hospitals and doctors, thanks to federal incentives to make the costly transition.
But of Kansas' 100 health departments, only Shawnee and Lyon qualified for the incentives because they are also Federally Qualified Health Centers.
In Lawrence, it made sense to implement an EHR even without the incentives, said Jennie Henault, director of Administrative Services. She said the new EHR system also will include new staff scheduling and reporting systems, both of which will greatly improve efficiency.
She said scheduling had been done in Excel, software made for spreadsheets. Consequently it was cumbersome to schedule a single appointment that spanned two program areas, such as immunizations and family planning. It also was not uncommon for staff members to double book or delete appointments scheduled by others.
"It was just very very easy to make mistakes or overwrite each other," Henault said.
Likewise, she said the reporting system will save staff members countless hours of manually compiling reports due to limitations of the current system.
"That was one of the biggest things we thought about, even after we found out we wouldn't be eligible for the incentives," Henault said. "Especially for time-sensitive information. For some grant funding and some mandated reporting, you have to be able to get that information quickly. And our health board wants more information, our director wants more information. It just doesn't make sense to keep wasting time manually counting things and going through pages and pages of reports."
An added benefit, she said, would be the capability of connecting to the statewide Kansas Health Information Exchange, which began exchanging patient data this summer. The exchange allows connected health care providers to use a private, secure network connection to quickly transfer digital health records instead of relying on fax machines or patients to deliver paper records.
When the health department would connect to the exchange, Henault couldn't predict — but when it does it will primarily be useful for immunization records and family planning records, such as Pap test results or medications lists, she said.
It makes sense for the state's largest health departments to implement EHR systems, said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. But it doesn't for most smaller health departments because of their lower client volume and limited budgets.
Kansas has become the first state in the country to connect to the national disease outbreak surveillance system via a digital health information exchange.
Officials at BioSense — the syndromic surveillance system at the Centers for Disease Control and Prevention (CDC) — said that the Kansas Health Information Network on Friday became the first HIE to begin contributing data. Various individual hospitals nationwide already are linked to the system.
Previously just one Kansas hospital — St. Luke’s South in Kansas City, Kan. — was connected to the CDC system, which keeps constant tabs on 89 syndrome categories as mandated by the Public Health Security and Bioterrorism Preparedness Response Act of 2002.
More hospitals contributing
With KHIN joining the system, 10 more Kansas hospitals are now submitting surveillance data to BioSense. And as more Kansas hospitals connect to KHIN, outbreak surveillance in the state will expand, a state health official said.
Kansas state epidemiologist Charlie Hunt said that his office at the Kansas Department of Health and Environment connected to BioSense this spring, but — with just one hospital contributing data — its usefulness for detecting an outbreak in Kansas was limited.
"The highway was built but there was only one car on it. Now there are a lot more cars traveling the highway and we'll be able to utilize the information better. As more facilities begin submitting data to BioSense through KHIN obviously the scope, the breadth and depth of information will be better for us," Hunt said. "This has a lot of potential for us to get information that we have not really had access to before, or information that we've collected in a manual process."
For example, during the H1N1 flu outbreak starting in 2009, KDHE asked hospitals to manually report influenza symptoms observed using a system made for reporting bed availability.
"That was a very labor-intensive process for them to go through their electronic health record system, manually pull out the number of patients (with flu-like symptoms) and then enter it into a separate system," Hunt said. "Once we get high enough participation in BioSense, we'll be able to query the system for influenza-like symptoms rather than have to have the hospitals report to us separately."
Among the 89 reporting categories are a wide variety of symptoms that — when aggregated across larger geographic areas — can reveal any number of possible outbreaks tied to a common diagnosis, including: asthma, abdominal pain, nausea and vomiting, hemorrhages, rashes and even spates of vehicle crashes.
Eliminating the routine use of antibiotics in livestock would be the single most effective way to improve public health by changing the way meat is produced in the U.S., said the keynote speaker at a conference here today.
The second most effective approach would be to aggressively enforce existing anti-trust laws and thereby increase competition in the livestock industry and foster more small-scale production, said Bob Martin, a senior policy advisor for Johns Hopkins School of Public Health in Baltimore.
"If we were only going to do two things, I think those would be the most transformative things we could do," Martin told about 75 attendees of “Healthy Farms, Healthy People: Agriculture and Health Summit."
The summit was organized by the Kansas Rural Center in partnership with the Kansas Farmers Union and the Kansas Health Institute. It was funded in part by the Centers for Disease Control and Prevention through a grant provided to the National Network of Public Health Institutes.
The policies that Martin listed as priorities were among 24 recommendations made in 2008 by the National Commission on Industrial Farm Animal Production, for which he was executive director.
"We looked at antibiotic overuse as the No. 1 public health concern because it adds significantly to the development of antibiotic-resistant bacteria that find its way into the community through a number of pathways," he said. "We're creating resistant bacteria, stronger bacteria that can infect human populations. And then we're seriously inhibiting our ability to fight those infections...I don't think it's alarmist to say we're on the verge of that point where we won't have effective antibiotics."
Overuse of antibiotics goes hand-in-hand with large-scale operations, Martin said.
"The type of operation that is most likely to misuse antibiotics are the large-scale operations where the animals are overcrowded and waste management is a problem. They stand over their own waste and it's flushed out from the barn a couple times a day. Those environments are really good breeding grounds for bacteria. So to suppress the infection rate, low levels of antibiotics are administered on a routine basis," Martin said.
"It's really true in this setting, the old adage 'what doesn't kill them makes them stronger.'"
The Kansas Livestock Association raised concerns about Martin’s views prior to the summit but no one from the organization attended or could be reached for comment afterwards.
However, the Kansas Farm Bureau, the state’s largest agriculture organization was represented. Meagan Cramer, KFB communications director, said her members welcomed discussions about the health impacts of modern, industrialized agriculture on consumers’ health. But she said some typical Kansas farmers should have been included in the line-up of presenters at the summit.
“That voice was maybe left out a little bit,” Cramer said. But she quickly added, “I think these types of discussions are good and they are becoming more mainstream.”
Consolidation big issue
Paul Johnson grows produce and lobbies for the Kansas Rural Center. He attributed much of the consolidation in the agriculture industry to the farm bill, the primary driver of federal agriculture and food policy. Among other things, it outlines agriculture subsidies and farm credits, conservation policy, and food and nutrition programs. It is the source of intense debate when the bill is renewed every five years or so.
"Concentration and consolidation have built off the farm bill politics. Eighty-five percent of all our farm payments from 1985 to 2009 went to 20 percent of farms. A third of our farms got no help at all from USDA payments," Johnson said.
As a result, Kansas has lost 90 percent of its hog farms since 1978. Today, he said, 319 farms account for 95 percent of hog sales in the state.
Over the same period, the number of Kansas dairies has dropped from 5,600 to 420, Johnson said. "Twenty of those have 65 percent of the cows," he said.
In beef production, "One percent of the cattle farms do half the sales in our state. About 10 percent do 75 percent of the sales," Johnson said.
Johnson said Kansas could create its own farm and food plan to counter consolidation forces and encourage smaller-scale agriculture.
"We have many resources to draw from in the state," he said, citing the beginning farm loan program out of Kansas Development Finance Authority, the Kansas State University Research and Extension, the marketing division in the Kansas Department of Agriculture. "People need to be players at this point," he said.
Support for local producers
The connection between the industrialization of agriculture and the nutritional value of the food Americans eat was what Emily Hampton and Ashley Craff came to hear about and discuss. The women work for Farmers and Educators United, a Lawrence-based program that facilitates getting locally produced food into childcare centers.
A child advocacy organization is criticizing Gov. Sam Brownback for restricting access to some programs that help low-income Kansans while more children and families are slipping into poverty.
Shannon Cotsoradis, chief executive of Kansas Action for Children, said recent changes made by the Brownback administration to tighten eligibility criteria for cash and child-care assistance programs are making it harder for some struggling families.
Cotsoradis cited data in 2012 KIDS COUNT report released on Thursday. It showed that the numbers of Kansas children enrolled in Medicaid and receiving food stamps had gone up significantly while the numbers receiving cash and child-care subsidies had gone down.
“You see this huge discrepancy in the data,” Cotsoradis said. “It just doesn’t make a lot of sense.”
Angela de Rocha, a spokesperson for the Kansas Department of Children and Families, defended the administration’s policy changes as efforts to encourage people to become more self-reliant.
“I think we should be praised, not criticized,” she said.
According to the new KIDS COUNT report, 21 percent of Kansas children are living in poverty, up from 18 percent in 2007. The average number of children enrolled in the Supplemental Nutritional Assistance (food stamp) Program rose to more than 136,000 in 2011 – an increase of nearly 40,000 since 2007.
Also, nearly half of all school-aged children in Kansas – 48.6 percent – qualified for free or federally subsidized lunches this year. That is an increase of almost 10 percentage points in four years.
Over the same period, the report shows that the number of families receiving cash-assistance through the Temporary Assistance for Needy Families program has been trending down. In 2011, there were 25,981 families that received assistance, down from 26,633 in 2007. Families receiving child-care assistance decreased to 19,735 in 2011 from 21,025 in 2007.
Officials at the Kansas Department of Children and Families anticipate that the TANF numbers will continue to drop. The official caseload estimate released earlier this month by the Kansas Legislative Research Department says the agency anticipates spending $2.4 million less from the state general fund to support the program in the 2014 budget year “due to the continuation of recent changes in policies.”
Cotsoradis said that explanation “confirms that they (administration officials) are creating barriers to those programs.”
But de Rocha said the declining numbers of families receiving cash and child-care assistance isn’t necessarily the result of the policy changes. She said it could mean that many have gotten full-time jobs because of the department’s insistence that they comply with job-search, training and part-time work requirements.
“It is either people who got a job or who don’t want to cooperate with the job-search and work requirements,” she said. “All we’re saying is ‘we’re happy to help you get back on your feet, but you need to find a job.’”
Cotsoradis said the changes to the assistance programs seemed at odds with Brownback’s campaign promise to make reducing childhood poverty one of his administration’s top priorities.
On Wednesday, the governor appointed a 12-member task force and charged its members to report back with “concrete ideas” on reducing childhood poverty.
“All too often in our state, children who are living in poverty today become tomorrow’s poor parents,” Brownback said. “Intergenerational poverty such as this affects our state’s long-term productivity and wellbeing. We need concrete ideas on how to change this pattern.”
The first task force meeting is scheduled for 10 a.m. Monday in the Kansas Board of Regents Conference Room on the 5th floor of the Curtis State Office Building in Topeka.
How methods used to produce food affect the health of those who eat it will be examined at a conference here Friday.
The “Healthy Farms, Healthy People: Agriculture and Health Summit" is scheduled from 9 a.m. to 4 p.m. Nov. 16 at Topeka’s Ramada Inn (register here). About 120 people are expected to attend, said organizer Julie Mettenburg, executive director of the Kansas Rural Center.
"The point of the day is to start a wide-ranging discussion about a variety of health issues in our communities that intersect with agriculture," Mettenburg said. "For example, the issues surrounding consolidation in the farm industry. We are concerned about antibiotic use, chemical use, and pollution of our water, air and soil. But we don't advocate a certain agenda that anyone will be pushing that day. We work with farmers to find alternative practices."
Among the scheduled speakers is Bob Martin, a senior policy advisor for John Hopkins School of Public Health in Baltimore. Mettenburg said he was invited to speak, in part, because of his experience as executive director of the National Commission on Industrial Farm Animal Production. Among other things, the commission recommended fostering more competition in the livestock market and banning non-therapeutic use of antibiotics in animal husbandry.
Officials at the Kansas Livestock Association recently raised concerns about Martin’s appearance because of his support for the "Meatless Mondays" campaign.
That initiative was briefly proposed this summer by officials at the U.S. Department of Agriculture as a way of encouraging agency staff to cut meat from their diets for a day. Protests from the beef industry caused the department to abandon the campaign.
Todd Domer, communications director for the livestock association, said he could not specify what Martin's tie was to Meatless Mondays other than "he's a supporter."
"We didn't ask to keep him off the program, but we did express some concern over what message he might deliver," Domer said.
"Obviously, we would oppose Meatless Monday for a variety of reasons," he said. "It's pretty apparent that animal agriculture is vitally important to our state. Our members are really proud to continue producing a safe, great-tasting, nutritious product in the most sustainable way we know how and we try to get better at doing that every day."
At least one representative of the association is planning to attend the conference, Domer said.
Mettenburg, a beef producer, said she doesn’t know whether Martin plans to mention the Meatless Monday campaign. But she acknowledged some topics at the summit could be controversial.
About 100 people rallied outside the Kansas Statehouse Nov. 9, urging state officials to expand Medicaid eligiblity as provided for in the federal health reform law.
A Lawrence pastor cast the expansion as a Christian imperative during a call-and-response exercise with the crowd.
“If Jesus was up in the Capitol would he make a choice to keep 130,000 people without care?” said the Rev. Joshua Longbottom, associate pastor at Plymouth Congregational Church in Lawrence.
"No," the crowd shouted.
“If Jesus was up in the Capitol, would he tell families that they just need to get better jobs so that they could afford to take care of themselves?” Longbottom asked.
Again, the answer was "no."
“Did Jesus say, ‘I’m sorry you can’t get to the well, Mr. Leper, but you need to cultivate some self-reliance’?” Longbottom said.
“No,” the crowd yelled.
“So I ask the question, Gov. Brownback, ‘What would Jesus do?” Longbottom said. “I thought the mark of his ministry was caring for the ill, caring for the sick, caring for the dispossessed, caring for the marginalized, caring the first for the least.”
Longbottom said he hoped the governor wasn’t a “…politician who puts on his Christianity like it’s a cardigan (sweater), using it to gain access to a constituency.”
Brownback, a conservative Republican, has been outspoken about his Christianity and penned a spiritual autobiography titled "From Power to Purpose."
He's been a consistent political foe of the Affordable Care Act, also known as ObamaCare, first in the U.S. Senate and later as governor.
He has said repeatedly that the majority of Kansans are opposed to the reform law and cites the success of the law's opponents in recent state elections as the proof.
Expansion not ruled out
Last week, the governor announced that he would block the state’s participation in a state-federal insurance exchange, one of the hallmarks of the new law. But unlike some Republican governors, he hasn't ruled out the possibility he would support some sort of Medicaid expansion.
"The Medicaid expansion is a separate issue" from the insurance exchange, said chief Brownback spokesperson Sherriene Jones-Sontag in an email Friday to KHI News Service in response to a question asking if the governor would oppose opening up the program.
"We are continuing to discuss options and alternatives with like-minded states and with our legislative partners in Kansas," she said.
The U.S. Supreme Court has upheld the Affordable Care Act, but said the law couldn't oblige states to expand their Medicaid programs. The law gives states the option of expanding their Medicaid programs to include adults earning up to 133 percent of federal poverty guidelines.
Kansas Insurance Commissioner Sandy Praeger said today that she wants to meet this week with Gov. Sam Brownback about how to move forward with implementation of the federal health reform law.
Specifically, Praeger said she wants to talk to Brownback about the state partnering with the federal government on a health insurance purchasing exchange. Kansas no longer has the option of designing its own online insurance marketplace but it can still partner on one with federal officials, if it acts quickly, she said.
Praeger said partnering with the federal government on an exchange would allow the state to maintain its authority to review and license insurance plans.
Praeger, a moderate Republican who supports the reform law, said she must let federal officials know by Friday, Nov. 16 whether the state intends to partner on an exchange. But she said she needs the governor’s blessing on that and a grant application her department has prepared, which must be submitted by Thursday, Nov. 15.
“The governor needs to agree that he won’t oppose us applying for the grant,” Praeger said. “He doesn’t have to give tacit approval necessarily, but just indicate it’s OK if we want to move forward on this.”
Brownback, a conservative Republican, voted against the Affordable Care Act as a member of the U.S. Senate and as governor has tried to block its implementation pending the outcome of a U.S. Supreme Court ruling on the law and then later the outcome of the presidential race.
Brownback in August 2011 rejected a $31.5 million federal grant intended to help Kansas develop an exchange as part of a program to develop models for other states to use.
Praeger said President Obama’s re-election means that the reform law won’t be repealed. It also means that states that have been slow to act will have to play catch up to meet approaching implementation deadlines.
Under the law, each state is to have an exchange operational by Jan. 2014.
“It’s time to stop resisting,” Praeger said.
Detailed spending proposals for the coming fiscal year prepared by officials at the state’s three top health agencies outline how Gov. Sam Brownback’s administration is planning to cap or cut spending on a broad range of health-related programs.
The governor’s formal budget recommendations for fiscal year 2014, which begins July 1, 2013, won’t be delivered to the Legislature until January when its new session begins. But agency chiefs were told as early as August by the governor to keep spending in check and to present alternatives for cutting 10 percent from each department’s upcoming state general fund budget.
The documents presented by the Kansas Department of Health and Environment, the Kansas Department for Children and Families, and the Kansas Department for Aging and Disability Services to the state budget office as part of the governor’s budget building process were obtained by KHI News Service and are made available here.
Administration officials declined to answer questions about their spending plans.
“We will not comment on the budget proposal at this time,” said Angela de Rocha, spokesperson for the Kansas Department for Aging and Disability Services and the Kansas Department for Children and Families.
Fading state aid
But there is abundant comment contained in the budget documents themselves and representatives of many, if not all, the organizations and programs that rely upon state health dollars have been advised informally within the past couple of weeks by administration officials of the planned spending limits and possible cuts. However, none of the representatives interviewed by KHI News Service had been given the full details laid out in the documents.
“We actually had a meeting with the secretary (Shawn Sullivan of the Kansas Department for Aging and Disability Services) but he didn’t give us any numbers,” said Cindy Luxem, chief executive of the Kansas Health Care Association, which represents for-profit nursing homes and some of the state’s providers of home and community-based services for the elderly.
“The providers at this stage of the game are not getting any kind of bump in the rates (for Medicaid services). The intention of the state is to keep the rates flat, essentially for the next two years, is what he told us,” she said.
Michelle Ponce, executive director of the Kansas Association of Local Health Departments, said she was alerted that the “reduced resources” budget proposed by the Kansas Department of Health and Environment could mean a cut in state aid to the local health agencies.
If adopted as outlined in the agency’s budget plan, 40 local health departments would see their state grants cut with the biggest decreases falling on the state’s largest local agencies.
“It’s maybe too early to tell you exactly what it would all mean,” Ponce said. “But it is unlikely all those agencies could absorb those cuts and maintain current services.”
Ponce said state support for local public health agencies hadn’t increased in years despite the added costs of inflation so any cuts would fall all the harder on the departments. She said association research had showed that since at least 1984, local governments have been stuck with absorbing the growing costs of health department programs as state aid has faded.
Health and Environment
Throughout the budget documents, officials note the need to hold down spending, though sometimes the notes are accompanied by caveats that seem to argue against some of the possible reductions.
At KDHE, officials said “that in recognition of the reality we find ourselves in as a state agency in the current budget environment, the (agency) will not be asking for budget enhancements” in fiscal 2014.
In fact, agency officials proposed total state general fund spending of about $1 million less than for fiscal 2013. About 80 percent of the agency’s $2.6 billion annual budget comes from fees, grants or federal aid as opposed to state tax dollars.
As part of the agency’s “reduced resources” options for cutting 10 percent from the state general fund portion of its budget, officials said they would trim administrative costs by almost 34 percent as a way to forestall more cuts to direct services.
Sixty officials from a variety of disciplines and from around the state gathered here today to grade Kansas' public health system by collectively answering a battery of 600 questions as part of the National Public Health Performance Standards Program.
Kansas is one of 23 states to conduct the evaluation and first did so in 2008, a year after the program was started by the federal Centers for Disease Control and Prevention. Four years ago, however, only officials from the Kansas Department of Health and Environment participated, said Brenda Nickel, director of KDHE's Center for Performance Management.
"The intent at the time was to also conduct it with our external partners statewide. But in 2008, the recession was going on and that opportunity was never fully realized," she said. "What's going on here today with our external stateholders, I think is going to provide a richer report because we actually have those individuals with boots on the ground in communities, as well as state-level partners, who are helping answer these questions."
Participants split into three groups to each grade the state's public health system on 200 questions, such as:
• Does the state public health system commit financial resources to workforce development efforts?
• Does the system utilize the leadership of the state public health agency in planning and policy development?
• Does the system have the professional expertise to carry out effective health communications?
The quantity of questions to be answered in a single day left little time for discussion of each question before the group voted on a grade.
The pace of the evaluation helped keep the group focused and moving along, said participant Michelle Ponce, director of the Kansas Association of Local Health Departments.
"We don't have time to get caught up in the weeds or thinking through every single in and out — we have to limit ourselves to the big picture and stay focused on the larger system. It doesn't give you time to get mired down into who does what and who's responsibility exactly is it. We're focused on the system — what is everybody's responsibility, what do we do well, and what are the gaps," Ponce said.
The annual report of births, deaths and other vital statistics by the state health department is now available. The new data shows a decline in the Kansas birth rate to the lowest level since the record keeping began in 1912.
The abortion rate also continued to decline and reached the lowest level since 1971, which is when abortion reporting began.
The birth rate in 2011, according to the report, was 13.8 live births per 1,000 population.
There were 39,628 live births recorded, about 2 percent fewer than reported for 2010. The rate was slightly lower than the previous low of 13.9 births per 1,000 population in 1973.
Births to young mothers, those under age 20, were down 8.6 percent.
Among the other report findings:
• Cancer again topped heart disease as the leading cause of death.
• Injuries from accidents and pneumonia/influenza each rose one level in the ranking of top 10 causes of death, coming in at fourth and eighth respectively.
• There were 247 infant deaths in 2011, a decrease of 2.4 percent from the 253 deaths in 2010. Pregnancy associated maternal deaths increased to 24 in 2011 from 19 in 2010.
• The number of reported abortions fell from 8,373 in 2010 to 7,885 in 2011. The ratio was 99.6 abortions per 1,000 live births.
→ More Kansas vital stats from 2011 in the full report, available on khi.org.
Amid national concerns that the seriously mentally ill are dying from preventable diseases, a leading Kansas healthcare philanthropy is about to make a down payment on a multi-year initiative aimed at integrating physical and mental health services for safety-net patients.
Within the next couple weeks, the Sunflower Foundation expects to open a competitive grant program that Chief Executive Billie Hall said likely would provide more than $1 million in funds to selected health providers focusing on integrated patient care. Foundation officials expect to award the grants by March.
“When we made the decision to get into this particular area,” Hall said, “we knew it would be a long horizon. We know we are in for five, maybe 10 years, depending on how things go in our state.”
The foundation’s board chose the initiative as a major priority about 18 months ago.
To date, Hall said, the foundation has spent about $50,000 sending some providers from different Kansas clinics to visit Cherokee Health Systems in Tennessee, which has 43 clinical sites in that state and a history of melding medical and mental health services.
Integration can mean having mental health and primary medical care agencies housed in the same building, said Melody Martin, a program officer with the foundation. But that is not the only way to do it, she said.
For instance, community health centers in Lawrence and Newton now have social workers or behavioral health specialists who work alongside the clinics’ medical teams.
At Heartland Community Health Center in Lawrence, behavioral health specialist Karin Denes-Collar technically is employed by Bert Nash Community Mental Health Center, which is located several blocks to the west of the clinic. But her office is at Heartland, where she consults daily with the medical staff about the conditions of various patients.
For example, she said, a patient with diabetes might also suffer depression in ways that could hinder the treatments for the underlying medical conditions. A homeless man with a chronic physical malady likely also struggles with a range of other problems that compound the illness. Assistance with those problems might best come from a social worker.
Reconnecting kinds of care
Area providers and national experts alike say that better coordination of care is essential to proper treatment for the mentally ill.
In an April 2009 paper, the National Council for Community Behavioral Healthcare said that persons with serious mental illness were dying 25 years earlier than the rest of the population largely because treatable conditions — such as diabetes and cardiovascular disease — had gone unmanaged.
“The bottom line is that the mind and body are connected,” said Tim DeWeese, director of clinical services at the Johnson County Mental Health Center in Mission. “And so the more physically healthy you are, the more mentally healthy you are going to be and vice versa. I think it’s really just reconnecting the two things. I don’t know where we got off base.”
The Sunflower Foundation is building upon a pilot project started two years ago by a subsidiary of the Association of Community Mental Health Centers of Kansas in collaboration with the Kansas Association for the Medically Underserved (KAMU)
Providers from nearly a dozen communities, including Heartland in Lawrence, were part of the pilot, said Connie Hubbell, director of governmental affairs at KAMU. The participants collected data for about a year starting in early 2011.
Undertaken with little funding, Hubbell said the pilot yielded results that were encouraging nonetheless. For instance, data compiled on 81 patients indicated an 8 percent reduction in monthly expenses per patient.
“So we know it’s out there,” she said. “We know it can happen. The integrated model is cost effective, it does save money, and it’s much more appropriate for the patient.”
Integration in action
One of the biggest challenges, Hubbell said, is successfully melding the consultative atmosphere of mental health with the often-frenetic pace that goes with providing primary care in a safety-net clinic.
A Kansas health consumer group is planning a post-election rally at the Statehouse in support of expanding the state’s Medicaid program.
Meanwhile, Lt. Gov. Jeff Colyer today headlined an event in Overland Park that was sponsored by a conservative think tank that opposes broadening the Medicaid program. Colyer, however, didn't make explicit what intentions, if any, the administration of Gov. Sam Brownback might have with respect to the issue.
Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said the group "wants to get the dialogue started," on the potential benefits for Kansans, if policymakers here decide they will open up eligibility to include adults earning up to 133 percent of federal poverty guidelines.
Currently, the state's Medicaid program is mostly restricted to poor children, pregnant women, the disabled and the elderly. A non-disabled adult rearing children is currently eligible for Medicaid, if his or her income is below 32 percent of the poverty level – about $5,200 a year for a young mother with two children.
Kansas’ eligibility threshold is among the lowest in the nation.
Affordable Care Act
Under the federal Affordable Care Act, commonly referred to as Obamacare, states would have the option of expanding their Medicaid programs to include adults with incomes at or below 133 percent of federal poverty guidelines or about $30,700 a year for a parent in a four-person household or about $14,900 a year for a childless adult.
Brownback, an outspoken critic of the health reform law, has said he won't consider any aspect of the health reform law's implementation, including a possible Medicaid expansion, until after the Nov. 6 election.
Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.
Governors in at least six states – Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas – have said they will reject the expansion, citing concerns that it would prove to be too expensive and would expand – rather than shrink – the role of government.
Governors in at least 13 states have said they will expand the program.
According to a preliminary estimate by analysts at the Kansas Health Institute, if the expansion is approved here it could add 130,000 people to Kansas Medicaid by 2019.
Colyer was the main speaker at a Kansas Policy Institute (KPI) meeting today in Overland Park that drew about 60 people. He confined his remarks to describing the administration's rationale and goals for its KanCare Medicaid reforms.
He didn't offer new information, but instead repeated points he and other administration officials have made in various venues since unveiling their plan about a year ago. He didn't touch on the question of Medicaid expansion and did not take queries from the audience before leaving for another engagement.
But earlier in the two-hour event, KPI President Dave Trabert said that expanding Medicaid in the state could increase the program's enrollment by 254,000 people by 2023 and increase state general fund spending on Medicaid by $4.7 billion within a decade.
Under the law, the federal government, starting Jan. 1, 2014, would finance 100 percent of the costs of covering the newly eligible Medicaid enrollees for three years: 2014, 2015, and 2016.
The federal match would drop to 95 percent in 2017; 94 percent in 2018; 93 percent in 2019; and 90 percent in 2020 and beyond.
Currently, the federal government picks up about 57 percent of the state’s Medicaid cost. The state pays the remainder.
Kansas has done a good job the past couple of years covering more children with health insurance.
In 2009, 8.2 per cent of children in Kansas were uninsured, according to a new report from the Georgetown Center on Children and Families. Two years later, the figure was down to 6.4 percent.
That 1.8 percentage point change was the seventh best improvement among states over the period, according to the report. Oregon and Texas improved the most, at 3.1 percentage points each. Missouri — which improved coverage by .2 percentage points — was among the bottom 10 states in reducing the percentage of its uninsured children.
Much of Kansas' increase in coverage for children is attributable to the state's Healthwave program — which insures children whose families earn a little too much to qualify for Medicaid — said Suzanne Wikle, director of policy and research for the non-profit advocacy group, Kansas Action for Children.
“In 2010, the eligibility level for our Healthwave program was increased to account for the fastest-growing group of uninsured children, who were just above the eligibility line at that point. So we made the program available to many more uninsured children in the state. That’s had a very big impact,” Wikle said.
Wikle said the state has also done a better job of marketing the Healthwave program. She's worried, though, that when Healthwave is incorporated into KanCare the name change may confuse some families and cause them to miss out on coverage they’re eligible for.
KanCare is Gov. Sam Brownback's plan to move most of the state's 380,000 Medicaid enrollees into managed care plans operated by three insurance companies.
Currently, large managed care companies only provide services to children and pregnant women from low-income families through HealthWave.
The authors of the Georgetown report say full implementation of the Affordable Care Act is the next opportunity to make substantial progress on insuring children.
Members of the governance committee for the Kansas Board of Regents have agreed that the full board should hear the pros and cons of a proposal to train mid-level dental practitioners.
Regents' officials said this week that discussion among board members likely would happen before the Legislature convenes in January, perhaps when the board that oversees state universities, junior colleges and technical schools next meets in November.
Bills authorizing the licensing of "registered dental practitioners" as a way of improving access to dental care for Kansans in rural and other underserved areas were considered by lawmakers in each of the past two sessions of the Legislature but were not advanced because of stiff opposition from the Kansas Dental Association, which represents about 75 percent of the state's dentists, of which there are fewer than 1,500.
Had the proposals become law, the mid-level practitioners would have been allowed to perform about 30 routine services and procedures — such as extracting loose baby teeth, taking X-rays and administering local anesthetic — that currently are limited to dentists. The practitioners, similar to a nurse practitioner, would be required to work under a dentist's "general" supervision, though the dentist would not be required at the technician's side.
Spokespersons for the dental association have argued that routine procedures quickly can turn dangerous and that allowing lesser-trained practitioners to do what dentists now do could put patients at risk.
But supporters of the measure, including a coalition that includes the state's safety-net clinics, argue that some people in Kansas, including children, have died due to lack of dental care and that putting more oral health workers into the field is essential for meeting the state's needs. They also cite studies from countries and states where the practitioners are licensed showing they provide good quality, cost-effective care.
Not enough dentists
According to the Kansas Department of Health and Environment the state's dental workforce is below the national average and shrinking. More than a dozen of the state's 105 counties have no dentist and many more than that have too few.
A proposal to create the new class of dental technician is expected to be before the Legislature again in the 2013 session, which begins in January.
Author and economist John Goodman is scheduled to talk about his ideas for reforming the U.S. health care system at an appearance next week at the University of Kansas Dole Institute of Politics.
Goodman sometimes is called "the father of health savings accounts," and has a new book: "Priceless: Curing the Healthcare Crisis." He co-wrote the 1992 book "Patient Power: Solving America's Healthcare Crisis."
He also developed the Health Care Contract with America, a five-point plan for reforming health care, which has been cited by the Congressional Health Care Caucus, a study group for Republican congresspersons and members of their staffs.
In his new book, among other things, Goodman calls for abolishing Medicaid and moving the program's beneficiaries into private insurance plans. Medicaid enrollees, under his plan, would instead get a $2,000 per person tax credit or refund that they could apply toward the purchase of private health insurance.
He also recommends replacing much of Medicaid outpatient spending for those who are not elderly or disabled with a "health stamp" system modeled on the food stamp program. Beneficiaries would be given the stamps and allowed to spend them as they saw fit for medical care. He also favors abolishing the Children's Health Insurance Program.
The main point of his book is that the current health system has neutered the function of pricing in the health care market, thereby driving up costs. Consumers, he argues, don't pay the real costs of medicine and largely are unaware of them. Providers aren't reimbursed for their true costs but instead take whatever the insurance companies and government are willing to pay.
"So, the overall conclusion of the book is that when we take prices out of the system we create perverse incentives," which have led to higher costs and inefficiencies, Goodman said in an interview with KHI News Service.
State health officials are raising concerns about the future of a federally funded program that helps county health departments prevent infertility in women by testing for the sexually transmitted diseases of chlamydia and gonorrhea.
“There hasn’t been an official announcement, but it certainly appears that the funding will be going away after January of 2014,” said Jennifer VandeVelde, who runs the Kansas Infertility Prevention Project at the Kansas Department of Health and Environment. “The assumption is that with the Affordable Care Act everyone will have insurance so we won’t need the funding we have now.”
Combined, chlamydia and gonorrhea are the leading cause of infertility, according to the Centers for Disease Control and Prevention (CDC).
The mandatory coverage provisions in the federal health reform law are scheduled to take effect Jan. 1, 2014.
What’s unclear, VandeVelde said, is how county health departments would offset the costs of testing patients who, despite new law’s requirements, will remain uninsured.
“A lot of health departments today are dealing with people who won’t be eligible for health insurance under any circumstances – the undocumented folks, for example,” said Greg Stephenson, head of the clinical services division at the Wyandotte County Public Health Department.
Also, thousands of Kansas adults whose incomes fall below 133 percent of the federal poverty level and who are currently uninsured would remain uninsured if Gov. Sam Brownback decides to opt out of the Medicaid expansion provisions in the Affordable Care Act.
Brownback, an outspoken critic of the reform law, has said he will not announce his decision about the Medicaid expansion at least until after the November election. Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.
The leading cause of infertility
Last year, KDHE conducted more than 27,500 tests for chlamydia and gonorrhea. Of those, 19,200 involved women younger than 26 years old and 8,400 of the tests involved older women and men.
Almost 9 percent of the younger women, 4 percent of the older women and and 17 percent of the men tested positive for chlamydia.
Less than 1.5 percent of the women and less than 5 percent of the men tested positive for gonorrhea.
“Chlamydia and gonorrhea are the leading cause of infertility, both in Kansas and nationally,” VandeVelde said, noting that between 10 percent and 15 percent of women with untreated chlamydial infections develop infertility-related problems.
According to KDHE, the state’s health providers – a group that includes health departments as well as family physicians, OBGYNs, emergency rooms, student health centers and other walk-in health clinics - reported more than 10,600 confirmed cases of chlamydia and 2,200 cases of gonorrhea last year.
It’s not known how many tests were performed by private laboratories because providers aren’t required to report tests that do not come back positive.
“Chlamydia is so widespread that it hits every demographic you can think of,” VandeVelde said. “It’s very across-the-board, very non-discriminatory.”
Those who test positive, VandeVelde said, are treated and counseled about “behavior changes” to limit their exposure to sexually transmitted diseases. They’re also asked to identify their sexual partners so that the partners also can be treated.
“The idea is to treat (partners) preventatively so that they do not re-infect the person who tested positive and so that they don’t continue to pass it along to anybody else,” she said.
Finding a way to cover costs
Assuming though that the Affordable Care Act remains on the books and that the federal funds for testing for chlamydia and gonorrhea go away, county health departments would have to figure out a way to cover the costs of testing those who remain uninsured, Stephenson said.
State health officials this week warned that flu season is upon us and encouraged Kansans to get vaccinated, if not for their own benefit, then for the sake of their family and community.
“By getting your flu vaccine before you see or hear about the first case of flu in your community, you give yourself and your family the best opportunity to stay flu-free throughout the season,” said Ryan Burns, immunizations director at the Kansas Department of Health and Environment.
“Although influenza can occur at any time, October is often thought of as the start of flu season, so acting now is a great way to get that protection,” he said. It takes about two weeks for the body to develop resistance to the flu virus after a vaccination.
Officials recommend that everyone 6 months and older get a flu shot annually. Some children age 6 months to 8 years may need two shots this year.
Flu shots are widely available at local health departments and many doctors' offices and pharmacies. This map identifies vaccine availability by area.
Every year, 5 percent to 20 percent of the population gets the flu, more than 200,000 people are hospitalized for flu complications and about 36,000 people die from flu. Some people — including infants, children, elders and people with certain health conditions — are at high risk for serious flu complications.
The board responsible for overseeing the digital exchange of Kansans' health records today unanimously approved transferring its duties to a state agency within a year, provided the Legislature acts to make the transfer legal.
If the Legislature amends the law, as is now expected, the functions of the Kansas Health Information Exchange would be transferred to the Kansas Department of Health and Environment by October 2013. Under the transition plan drafted by KDHE, the 17-member KHIE board currently appointed by the governor would become an advisory committee appointed by the KDHE secretary.
The goal of transferring the authority to KDHE is to reduce costs. Operating the board was expected to cost about $400,000 a year as an independent entity versus about $54,000 a year if the board's regulatory functions are assumed by the state.
The decision came at the same time that health information exchange is beginning in Kansas.
"This is a way to get the state to have some skin in the game. Right now the only people who have skin in the game are (medical) providers," said board member Jerry Slaughter, who also is executive director of the Kansas Medical Society.
Leading up to the decision, some board members and others had expressed concern that a state agency wouldn't represent the interests of patients or health care providers as well as an independent board would do so.
Related story: Kansas breaks ground on statewide digital health network
A range of political and economic uncertainties are hindering the ability of hospital officials to plan for the future, according to a report released today by the Kansas Hospital Association.
"The 2012 election has moved the health care debate to the forefront, which is good," the association's chief executive Tom Bell wrote in an editorial accompanying the report. "However, the ongoing nature of the debate complicates hospitals’ ability to make investments."
Among the unknowns cited in the 16-page report:
• The impact of the 2012 election on Medicare reform and on implementation of the Affordable Care Act,
• The uncertain future for federal disproportionate share payments, which compensate hospitals for treating uninsured patients who do not pay, and
• Whether Kansas will expand Medicaid eligibility as provided for under the ACA.
"Cuts to entitlements, especially significant federal cuts to Medicare, could jeopardize hospitals and physicians — limiting access to care," Bell said. "The state’s pending decisions about Medicaid expansion also will have a substantial impact, at a time when hospitals have already surrendered significant Medicare revenue through the ACA with the expectation of expanded coverage."
Under the health reform law, about 130,000 additional Kansans are expected to become eligible for Medicaid in 2014. The state currently has about 350,000 people directly benefiting from Medicaid services. In anticipation that hospitals would be providing less uncompensated care to uninsured patients because of expanded Medicaid eligibility, the ACA also reduced the disproportionate share payments.
While the U.S. Supreme Court ruled much of the health reform law constitutional, its decision granted states leeway to decide if they will expand eligibility.
If Kansas opts not to expand its Medicaid coverage, Bell has said, the state’s hospitals would be put in a position of still having to care for thousands of uninsured people in their emergency rooms while losing millions of dollars in federal disproportionate share payments.
Kansas Gov. Sam Brownback has reiterated his opposition to the Affordable Care Act in statements since the ruling, but he has stopped short of saying the state won’t implement the Medicaid expansion on schedule in 2014.
"Decisions regarding the expansion of Medicaid under Obamacare will not be made until after the November elections. The Brownback administration does not speculate on hypotheticals," according to a statement issued by the Governor's Office.
State insurance regulators are preparing a recommendation for Gov. Sam Brownback on what basic benefits should be available to Kansans who seek health insurance through the new online purchasing exchange that federal officials expect to be operational here within about 16 months.
A three-hour hearing to collect public input on what should constitute the state’s “essential health benefits” benchmark plan is scheduled for Wednesday. It is set to start at 9 a.m. in Shawnee Room A at the Maner Conference Center, which is next to the Capitol Plaza Hotel in Topeka.
“Our plan is to get some summary information (including a recommendation) over to the governor within a week or so after the hearing is over, and at that point it will be up to him to decide if he wants to make an election,” said Linda Sheppard, director of the accident and health division at the Kansas Insurance Department. Sheppard also is the agency’s project manager for matters dealing with implementation of the Affordable Care Act, the controversial federal health reform law that Brownback has pledged to have no part of until after the November presidential election.
Brownback, like other conservative Republicans, opposed the Affordable Care Act, first as a U.S. senator and then when he campaigned for governor in 2010. In August 2011, under pressure from GOP party activists, he spurned a $31.5 million federal “innovator” grant to Kansas to help the state create a health insurance exchange model for use here and possibly in other states.
He then said his administration would have nothing to do with “Obamacare” until after the U.S. Supreme Court ruled on the reform’s constitutionality. After the court largely upheld the law in June, he said he would do nothing to implement it until after the election.
Republican presidential nominee Mitt Romney and most Republicans running for Congress have vowed to repeal the law as a first order of business, if elected. In Kansas, conservative Republicans continued to use the reform law to bludgeon more moderate opponents in the party’s August primaries and were mostly successful with the tactic.
Insurance Commissioner Sandy Praeger is a moderate Republican who helped craft portions of the Affordable Care Act as part of her work on behalf of the National Association of Insurance Commissioners. She has consistently said that the law has shortcomings but allows flexibility to states in how it is implemented in some areas, and that Kansas should exercise those options in order to have programs more in tune with the state’s needs and desires.
The health reform law stipulates that the federal government will run the insurance exchanges in states that choose not to create their own and will have them up and running by Jan. 1, 2014. Likewise, in states where governors decline to choose the models for “essential benefits” offered through the exchanges, the federal government will do so.
Sheppard said if the federal government chooses the benchmark plan for Kansas, it could be one that is less affordable than a plan selected by those more familiar with the Kansas market.
Spokesmen for Brownback this week said they were unable to say whether the governor would pass on making a recommendation regarding essential benefits as he did on returning the exchange grant.
According to Sheppard, federal officials have set a Sept. 30 deadline for hearing from governors on their benchmark plan choices.
After nearly four hours of discussion Wednesday, the board responsible for regulating digital health information exchange in Kansas postponed its vote on a proposal to dissolve and turn its regulatory authority over to a state agency.
Instead, members of the Kansas Health Information Exchange board decided to form a committee to develop a list of the dissolution proposal's pros and cons and return with a recommendation for the board to consider at its Sept. 12 meeting.
In Kansas, privately owned networks handle the transfer of patients' digital health records over a health information exchange — which went live last week. The KHIE board was set up in 2010 as a public-private regulatory body to be independent of political influence.
The proposal to fold KHIE's functions into the Kansas Department of Health and Environment would eliminate more than half of KHIE's $400,000 projected annual costs and transfer the rest to taxpayers. Under the proposal, the 17-member KHIE board currently appointed by the governor would become an advisory committee appointed by the KDHE secretary.
"I feel like we haven't fully vetted and understand the long-term implications of making this transition," said board member Karen Braman.
"I absolutely agree that we have to look at efficiencies in operations wherever we can. That's going on in every sector, every business, every household in the country right now. And I do think we have to capitalize on the synergies that can be gained in collaboration with KDHE. I think that's been one of the cornerstones of this public-private partnership that we've all been involved in for so long," Braman said.
Board member Jackie John of the Great Plains Health Alliance asked what assurance there would be that KDHE would continue to ensure the privacy and security of patient health information.
"When the state goes through their budgeting process, how do we know that there's going to be enough value, that this process is going to continue with the resources necessary to provide the quality of services we're committed to?" John said.
"At least until a change in administration, there's a commitment to do this. But I'm not going to sit here and say that we can guarantee things for all eternity — that's just not realistic," said Aaron Dunkel, deputy secretary at KDHE. "At least with this administration, which we're hoping will be a little bit longer, we've got a commitment."
Note: Updated 8:30 a.m. Aug. 7 to reflect last-minute campaign contributions.
A national organization that polices the accuracy of charges made in political campaigns has said mailed materials being used in the coordinated effort to oust some incumbent Republican state senators in Kansas are misleading.
FactCheck.org is a nonprofit project of the Annenberg Public Policy Center of the University of Pennsylvania.
The group examined direct-mail pieces that accused some incumbent senators of scuttling efforts to pass a state constitutional amendment opposing the federal health reform law commonly known as the Affordable Care Act or Obamacare.
“One mailer makes the slippery statement that the legislation ‘would have amended the Kansas Constitution to allow you to vote to opt-out of Obama’s new health care law,’” FactCheck.org researchers concluded. “That’s true. Kansans could have voted – but purely on a symbolic level.”
Kansans go to the polls Tuesday to decide a host of races in Republican and Democratic primaries. The most heated and expensive races so far have been those of Republicans seeking to hold or capture Senate seats.
For the most part, the mailed information has been sent on behalf of conservative Republicans vying against GOP opponents who are considered more moderate in their views.
Supporters of the proposed amendment, which over the course of two legislative sessions failed to get enough legislative backing to make it onto the ballot, said it would have allowed Kansans to opt-out of the federal health reform law. It would not have created that option and some opponents of the measure said it might mislead Kansans into thinking, for example, that they could choose not to have health insurance and avoid the federal tax penalty the law would impose on those who can afford health coverage but decide against it.
The proposal passed the House earlier this year but failed by one vote in the Senate, with six moderate Republicans voting with Democrats to deny it the needed two-thirds majority. A similar statewide ballot measure was approved in Missouri.
Some of the targeted moderates voted for the amendment but also voted for a provision to keep it off the ballot, if the U.S. Supreme Court upheld the health reform law, which it did in June.
Americans for Prosperity-Kansas, an organization that advocates for smaller government and lower taxes, produced several of the direct-mail pieces.
As a nonprofit advocacy group, AFP-Kansas doesn’t have to disclose the names of its contributors or its campaign expenditures. However, it’s known that Wichita businessmen Charles and David Koch were founders and major contributors to AFP.
State campaign finance filings show that their company, Koch Industries, has contributed about $175,000 to other organizations involved in the effort to defeat eight to 10 moderate Kansas Republican senators. Much of it – $125,000 - went to the Kansas Chamber, which has spent more than $675,000 on this year’s campaigns. More than $300,000 of that total was spent in the last few days.
“We need to be more competitive,” said Eric Stafford, a Chamber lobbyist. “Our state has a lot of attractive elements; one of those, unfortunately, is not its tax policy.”
Many of the moderates being targeted for defeat resisted Brownback’s successful push last session to cut income taxes. Brownback and the Chamber’s leaders said the tax cuts would stimulate the Kansas economy.
Health reform as a wedge issue
A recent mailer paid for by the Chamber’s political action committee features a photo of Sen. Vicki Schmidt affixed to a rubber stamp. The piece accuses the Topeka moderate of siding with the Democrats and President Obama on a host of key economic issues and charges that she voted against “efforts to stop Obamacare.”
Stafford said it was fair to focus on the health reform issue even though leading constitutional scholars said the amendment would have had no effect had it passed.
“Kansans didn’t have the opportunity to voice their opinion,” he said. “For our state Legislature not to give Kansans the right to voice their opinion on their ability to opt-out of the most controversial health care reform to take place in our country is unfair.”
Conservative State Rep. Joe Patton, who has the Chamber’s endorsement, is challenging Schmidt in the primary. The Chamber spent more than $17,000 on mailings to help Patton in the final days of the campaign.
The mailers, Stafford said, helped educate voters about who voted against the opt-out amendment or to weaken it.
Mark Desetti is on the other side of this year’s high-stakes campaign for control of the Kansas Senate. He lobbies for the state teacher’s union, the Kansas National Education Association.
The group has spent more than $237,000 this election cycle, much of it to help Democrats and moderate Republicans.
Desetti was critical of conservatives for using the federal health reform law as a wedge issue in state legislative campaigns.
“This election has nothing to do with Obamacare, and yet that’s what they’re running their campaign on as if the state Legislature is the one that is going to make that decision,” Desetti said. “It (the health reform law) has nothing to do with the Kansas Legislature.”
The Legislature could play a lead or major role in deciding whether the state will choose to expand eligibility for the Medicaid program. The federal law would expand eligibility to all adults earning 138 percent or less of federal poverty guidelines. But the U.S. Supreme Court, in its ruling, found that state’s have the option of expanding the program or not. If Kansas chooses to widen the program, an estimated 130,000 Kansas are expected to directly benefit from the coverage. Currently, about 383,000 Kansans are enrolled in Medicaid, but virtually all adults are barred except for pregnant women, frail elderly or disabled persons who are very poor.
But the Medicaid expansion issue has not been raised in any of the races to date. Patton, who held a Monday afternoon press conference to blast his opponent’s “lies and deceit,” for questioning his commitment to conservatism, indicated he was unfamiliar with the issue and said ”I would have to take a look at that.”
Talk of repealing the Affordable Care Act is partisan bluster that won’t come to pass even if Republicans sweep the November elections, a top Obama administration health care official predicted at a forum here today.
“Even those people who are talking about repealing, privately, they acknowledge that no, the law is here to stay,” said Jay Angoff, director of the U.S. Health and Human Services Department region that includes Missouri, Kansas, Nebraska and Iowa.
Angoff said that even if Republicans control the White House and U.S. House following the election, they would not have a large enough majority in the Senate to push through legislation to overturn the law. Senate rules require 60 votes to advance most legislation.
Angoff is a former Missouri insurance commissioner and has served as an advisor to Health and Human Services Secretary Kathleen Sebelius on health insurance cost and coverage issues. The forum, organized by the Health Care Foundation of Greater Kansas City, drew an audience of about 50 people.
'When the dust settles'
Kansas State Rep. Jim Denning, an Overland Park Republican, disputed Angoff’s comments, including taking issue with the director’s analysis of the potential congressional repeal. Denning is the retired chief executive of Discover Vision Centers, which has eight locations in Missouri and Kansas.
Angoff also predicted that states eventually would go along with the expansion of Medicaid eligibility included in the Affordable Care Act.
“When the dust settles,” he said, “states are going to realize what a terrific deal this is.”
In its June 28 ruling on the reform law, the U.S. Supreme Court left it up to the states to decide if they want to participate in the expanded Medicaid program.
Under the law, the federal government would pay 100 percent of the costs of the newly eligible Medicaid enrollees when the provision takes effect in 2014, gradually reducing its share to 90 percent by 2020.
The expanded eligibility would take in low-income residents under the age of 65 who earn up to 138 percent of the federal poverty level.
Kansas currently covers more than 350,000 individuals under its Medicaid program. Preliminary estimates project the state’s enrollment could increase by about 130,000 individuals under the health law expansion.
The Kansas Medicaid program costs about $2.8 billion a year. The federal government currently covers about 60 percent of the cost.
Good for small business
Angoff also said the Affordable Care Act was a great deal for small businesses, despite the fact that the National Federation of Independent Businesses was a lead challenger of the law in the suit before the Supreme Court.
He noted a provision that provides tax credits to businesses with 25 or fewer workers that offer health insurance to their workers.
Roughly 360,000 small businesses have already received assistance under that program, Angoff said, and more than 1 million more are eligible.
“We think it’s a great victory for the American public,” Angoff said of the Supreme Court decision.
Denning said it wouldn’t take a 60-vote majority in the Senate to repeal the Affordable Care Act.
He said the Senate could overturn the act with a simple majority through the budget process, much the way the law was passed in the first place.
He also disagreed that the Medicaid expansion was a good deal.
“This is not free money,” Denning said. “The federal government has no money.”
He said the federal government would have to run up its debt to pay for the Medicaid expansion.
He also said he was concerned that the federal government would pay for the expansion the first few years but then would pull back, leaving states to pick up more and more of the tab.
Denning also said the tax credit program for small businesses has not been nearly as popular as Angoff made it seem.
“He’s just talking sound bite stuff there,” Denning said of Angoff's remarks.
The tax credit program was complicated and resulted in costly plans that insurance brokers had little luck in pushing with their business customers, he said.
The chief executive officer of one of the private insurance companies that recently signed Medicaid managed care contracts with the state of Kansas said today that states shouldn’t refuse the offer of additional federal money to expand their programs.
James Carlson, CEO of Amerigroup, made the comment during a discussion with Wall Street analysts about his company’s potential sale to insurance giant WellPoint.
“When you step back from this, there are billions of dollars of federal money that are going to flow into states,” Carlson said in a report published by Politico. “We think the states are going to need to take it.”
Kansas insurance officials are evaluating WellPoint’s bid for Amerigroup, which is one of three companies selected by the state to manage care provided to the approximately 350,000 poor, elderly and disabled Kansans enrolled in Medicaid. The other two are United Healthcare of the Midwest, a subsidiary of United Healthcare, and Sunflower State Health Plan, a subsidiary of Centene.
Several Republican governors have said they don’t intend to expand eligibility for their Medicaid programs now that the U.S. Supreme Court has ruled that the federal government can’t withhold its share of funding for the program in states that decline to do so.
Kansas Gov. Sam Brownback has reiterated his opposition to the Affordable Care Act in statements since the ruling, but he has stopped short of saying the state won’t implement the Medicaid expansion on schedule in 2014.
Brownback spokesperson Sherriene Jones-Sontag said the governor still favors repeal of the health reform law and has urged voters to reject it at the polls in November by voting against President Obama’s re-election.
The expansion would result in a more dramatic increase in Medicaid eligibility in Kansas compared to other states. Currently, Kansas adults with dependent children can’t qualify for the program unless they earn less than 27 percent of the federal poverty threshold – about $6,000 for a family of four. Adults without children aren’t eligible for Medicaid unless they are disabled.
The ACA expansion would make everyone who earns less than 133 percent of the poverty threshold eligible for Medicaid. That means a family of four could earn up to about $30,000 and still qualify.
If implemented, the expansion could add as many as 150,000 Kansans to Medicaid rolls.
Related coverage on KHI.org:
Republicans are working still to repeal it, but even before the U.S. Supreme Court ruled that the Affordable Care Act was constitutional, many of its major changes were under way for Kansas hospitals, doctors and other medical providers.
In fact, some representatives of doctor and hospital groups in Kansas and nationally say that many key requirements of the law were inevitable or bound to happen with or without the law, simply because the status quo of the health care industry was unsustainable because of its costs.
In 1965, U.S. health care spending accounted for about 6 percent of the gross domestic product; by 2009, it represented about 17 percent. One culprit for the rising cost, experts say, has been payment systems that reimburse providers more for the volume of their services than for the quality or effectiveness of the care.
“I don't want to downplay the significance of the (Supreme Court) ruling,” said Tom Bell, chief executive of the Kansas Hospital Association, “but I think it’s been clear for some time that a lot of the ways that the system is changing - the movement away from fee-for-service, value-based purchasing, those sorts of things - those things were going to continue whether this law was struck down or upheld. ... So from that perspective, (the decision) was maybe not quite as momentous as we’ve been hearing on the cable news networks.”
A report on the ACA by the national Physicians Foundation published soon after the law was passed in 2010 generally was negative about the reform’s anticipated consequences, particularly for the 32 percent of the nation’s doctors working in individual, private practices of one or two physicians. For them, the authors concluded, the law almost certainly means that their forms of practice “will be largely, though not uniformly, replaced” by new arrangements that will make many of them salaried employees of hospitals or larger group practices.
Nonetheless, the report concluded, “health reform was necessary and inevitable. The impetus of informal reform would likely have spurred many of the changes (required by the ACA) independent of formal reform.”
Quietly moving forward
So as politicians continue to fight over the law, forward-looking hospitals and doctors for at least the past two years quietly have been preparing for and adopting its various provisions.
“The Supreme Court’s ruling keeps in place improved access to health care through expanded insurance coverage and important insurance reforms, which were key elements of the Affordable Care Act,” said Jeff Korsmo, chief executive of Via Christi Health, a Catholic-affiliated system that is the largest private provider of health services in Kansas. “The way we deliver health care has been changing since the Affordable Care Act took effect two years ago, and it will need to change even more dramatically in the years ahead.
“The growth in the cost of health care in the United States is simply unsustainable,” Korsmo said after the court ruling, “and it’s going to get worse because 10,000 baby boomers a day are reaching Medicare age. Those costs, combined with our federal and state governments’ fiscal challenges, all call for major change in health care.”
The head of the Kansas Hospital Association said today that most of the group's member hospitals have accepted the U.S. Supreme Court decision to uphold the Affordable Care Act and are ready to embrace reform.
“The number one thing I’m hearing from my people is, ‘Oh my gosh, are we going to have to go through this health reform political debate again?’” said Tom Bell, noting that he and other health care officials had hoped the ruling would give them a clearer picture of the future.
So far, he said, that’s not happened.
“I’m not so sure that – because of our political environment – we have any more certainty today than we did last week,” he said. “It’s hard to plan.”
Bell spoke during a Kansas Health Institute-sponsored panel discussion on the court’s ruling. Also participating on the panel were:
• Bill Rich, professor of constitutional law at Washburn University School of Law.
• Kansas Insurance Commissioner Sandy Praeger.
• Jay Angoff, director of the U.S. Health and Human Services regional office in Kansas City.
Angoff told the audience that over time “cooler heads are going to prevail” as the public learns more about the law’s benefits and costs.
The court's decision left intact the law's requirement that everyone who can afford health insurance buy it or pay a penalty. But the ruling also made the law's planned Medicaid expansion optional for states. Several Republican governors already have said they do not intend to expand Medicaid eligibility in their states. Gov. Sam Brownback hasn't said yet what his intentions might be with respect to the expansion, which could mean as many as 130,000 additional Kansans would gain eligibility.
Brownback has said he would take no steps to implement the Affordable Care Act until after the November elections, based on the assumption that Republicans will prevail in their bid for control of the White House and Congress and then repeal the law.
If Kansas opts not to expand its Medicaid coverage, Bell said, the state’s hospitals would be put in a position of still having to care for thousands of uninsured people in their emergency rooms while losing millions of dollars in federal disproportionate share payments.
Currently, the disproportionate share payments are meant to help hospitals offset the costs of caring for the uninsured.
Under the Affordable Care Act, Bell said, the payments would be phased out because it assumes the vast majority of the hospitals’ patients will be insured under Medicaid or otherwise by 2014, when the law's major coverage provisions are scheduled to kick in.
“There are a lot of things that really need to be looked at closely,” Bell said.
A Wichita legislator who attended the event said he thought fellow lawmakers would act in the 2013 legislative session to authorize Kansas' participation in the Medicaid expansion.
“If you’re a legislator and the hospitals’ (profit) margins in your district are tied to their DSH (disproportionate share) payments, how do you vote against giving them more patients with insurance through a Medicaid expansion if you know there isn’t going to be anything to replace the DSH payments with?” said Rep. Jim Ward, a Wichita Democrat who serves on the House Health and Services Committee. “At what point does ideology get by the practical reality?”
→ Related story: States balk at expanding Medicaid
In the wake of today's U.S. Supreme Court ruling, Kansas could still avoid ceding total control of its health insurance exchange to the federal government if it moves quickly, Insurance Commissioner Sandy Praeger said.
“That’s probably the best-case scenario now from an exchange standpoint,” Praeger said.
But that would require a meeting of the minds between Praeger and Gov. Sam Brownback and meeting a mid-November deadline for alerting federal officials to the state's intentions.
Last year, Brownback returned a $31.5 million federal grant that would have helped the state develop its own exchange. And today, after the court's decision, the governor vowed he would do nothing to implement the Affordable Care Act's provisions until after the November elections.
“Stopping ObamaCare is now in the hands of the American people," Brownback said. "It begins with electing a new president this fall.”
Opposition from Brownback and Republican legislative leaders resulted in Kansas missing deadlines for establishing its own exchange. Under the federal law, each state must have an operational exchange by Jan. 1, 2014, with plans for it certified by Jan. 1, 2013. States that choose not to implement an exchange on their own would cede that authority to federal officials.
Kansas missed the cutoff for developing its own exchange but could still partner with the federal government on one, an arrangement that Praeger said would allow state officials to set rules for insurance company participation in the online marketplace and direct consumer assistance efforts.
“Plan management and consumer assistance are two functions that our industry and our agent community are most concerned about. So, I think they would like us to retain control,” Praeger said.
Praeger said federal officials have told her that she doesn’t need explicit authorization from Brownback to proceed. She could sign the letter declaring the state’s intention to partner with the federal government on an exchange.
Despite those assurances, Praeger, a moderate Republican who supports the health reform law, said she doesn’t want to circumvent Brownback, a conservative Republican who continues to fight the law.
“Even if I’m allowed to sign the letter, I’m not going to do that unless the governor at least agrees they won’t try to block our efforts,” Praeger said. “After the dust settles, I think we (Praeger and Brownback) will have a conversation and we’ll sort through all of the issues.”
As outlined in the Affordable Care Act, individuals, small-business owners and people whose incomes qualify them for federal subsidies and tax credits would shop for policies using the exchange websites that would help the shoppers sort through coverage and price options. The exchange also could be used to determine eligibility for the Medicaid program, eligibility for which would be expanded under the law where states choose to do so.
→ More in-depth coverage of the Supreme Court's ruling on health reform and its implications for Kansas at khi.org/aca-ruling.
For years, poor patients in this southeast Kansas community have relied on a free health clinic that operates on Thursday afternoons out of a Bible school classroom.
In its heyday, the Parsons Community Clinic could count on about a dozen primary care physicians and an equal number of nurses to volunteer at the First Assembly of God building at North 16th Street and Dirr Avenue. It still treats about 35 to 45 patients each week for everything from rashes to diabetes.
But now, with the volunteers getting up in years, the clinic faces an uncertain future — and local medical leaders essentially are trying to put it out of business.
“That is our hope, yes,” said Dr. Stephen Miller, a retired surgeon who helped found the clinic 15 years ago.
n its place, though, members of the Southeast Kansas Healthcare Collaborative are proposing a model that, at least according the group’s research, does not exist anywhere else in the country.
The plan is to create a rural health network that would connect providers via computer to create a “virtual” federally qualified health center, or FQHC, serving Labette, Neosho and Wilson counties. FQHCs typically are bricks-and-mortar facilities offering primary care services in underserved communities.
Led by Labette Health, the hospital in Parsons, and its Chief Executive Officer Jodi Schmidt, collaborative members hope the idea is unique enough to earn funding through the new Health Care Innovation program administered by the federal Centers for Medicare and Medicaid Services.
They have an $11.4 million grant request pending before the agency that would allow them to develop and implement the plan.
The collaborative is targeting an area with about 50,500 residents in a corner of the state that has some of the worst health outcomes among Kansas’ 105 counties, according to the County Health Rankings from the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation. This year’s ranks are Labette (91), Wilson (87) and Neosho (83).
Members of the collaborative are striving to achieve the “triple aim” of better individual care, better population health and lower per capita health care costs.
The virtual health center plan
Under the plan, organizers would establish a nonprofit organization – overseen by a 21-member board – to manage the virtual community health center. The center would contract with primary care physicians and midlevel providers at hospitals in the three counties.
To help Kansans better understand the health reform law, the problems it was intended to address and the issues that prompted Kansas and 25 other states to challenge it in court, the Kansas Health Institute recently talked to several experts. Excerpts from those conversations are featured in this collection of short videos. Each offers an informed perspective on the law and the controversy that surrounds it as the U.S. Supreme Court prepares to rule on its constitutionality this month.
Maynard Oliverius, CEO, Stormont-Vail HealthCare Topeka
Oliverius, a longtime hospital administrator, provides a historical viewpoint on health reform and its ultimate goal of improving access to health care for all Americans. “The Affordable Care Act is really a continuation of a public health policy that was formulated really back in the 1940s,” he says. As part of the health reform law passed in 2010, he says, hospitals agreed to forgo $155 billion in Medicare compensation with the expectation that 32 million Americans who now are uninsured will gain coverage through Medicaid or the insurance exchanges.
Oliverius acknowledges that the health reform law has flaws but says, “What I would hope is that Congress would look at the law, tweak, fix those things that need to be adjusted and fixed, and try to move away from the political ideology war that seems to be going on today.”
This is the first of six short videos. Click here to watch the next video, or jump to others in the series below...
Jennifer Brull’s father needed urgent medical attention.
Brull, herself a physician, was helping him collect everything he needed, including his most recent laboratory and scan results. Then she learned that one set of her father’s X-rays were at a hospital four hours away.
"We had to drive to pick them up," she said, recalling the incident, which occurred earlier this spring. "It was a real pain in the butt. You know, it's during a stressful time and we were dealing with a bunch of other things. This was just one more thing that we have to deal with, something that should have been easy. There's no reason in this day and age that we shouldn't have been able to accomplish that electronically.”
Dr. Jennifer Brull, who practices family medicine in Plainville, is a national leader in adopting electronic health records.
It isn’t the technology itself that is the barrier to more medical providers exchanging electronic records, she said, but the lack of a secure network to transmit them without risking patient privacy.
"We said, 'Just email it — it's fine, we'll sign a waiver.' They said they just couldn't do it," Brull recalled of the hospital’s refusal to transmit her father’s X-ray records and spare the family the long drive.
Developers of a new statewide digital health records exchange say the needed secure network is coming to Kansas this summer. They call it a groundbreaking event that is expected to improve patient care and help cut medical costs by avoiding redundant and ineffective treatments. It’s also expected to reduce errors.
The statewide health information exchange is scheduled to go live July 1, allowing medical providers registered with the network to share and search for patient records.
Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, said the exchange would safeguard patient privacy.
"We can assure patients that this information will be secure and safe and only available to those providers that need it, and at the time they need it," he said.
Patient information available on the network at first will be limited to demographics, medications, allergies, lab results and medical history, including diagnoses, procedures, surgeries and immunizations. But officials at the Kansas Health Information Exchange Inc. predict the system will grow to include more kinds of information, such as a doctor's notes or dictation recordings.
Substance abuse data will not be available on the network unless explicitly authorized by a patient.
About a third of Kansas patients receive care from a provider who is or will be connected to the exchange in the near future, officials said.
Benefits of exchange
As it is more widely adopted, health information exchange, or HIE, will take the place of paper records, which are typically transferred via fax, discs, mail or by patients themselves. And quicker access to more complete patient information should translate into benefits for patients.
"Right now we wait sometimes a month or more to get records," Brull said. "That time delay certainly impacts how you provide care to that patient."
She said the current paper system relies heavily on the patient to relay information from one care provider to the next. But too often patients don't know exactly what was done or learned by another provider.
"If you know real information, you're a lot less likely to order another test," Brull said. "That's what the free exchange of information gets you — you've helped the patient and eliminated costs."
Less paperwork also will mean less administrative cost, she said.
"I hope people look back 20 years from now or 50 years from now and say, ‘This was when health care in the United States changed. There's way less cost and better health care,’" Brull said.
→ Continue reading about health information exchange at khi.org/HIE — including information about network security and privacy concerns that patients need to know.
New privacy notices
Starting June 1, patients of Kansas health care providers who are connected to the new statewide network will receive privacy notices telling them that their health records may be shared electronically, under the same legal protection that currently applies to their paper-based health records. Those who don’t want their records to be available on the network must mail in an "opt-out" form, which is available at the website KHIE.org.
The population of Stevens County is less than 5,800, but its health department has more than 7,000 patients, and it's out of space.
Many of those patients are so-called Low German Mennonites, or Mexican Mennonites, said Paula Rowden, administrator of the health department in the southwest corner of the state. They typically have come to Kansas from Mexico, looking for jobs in agriculture or livestock.
"They seem to be at the greatest risk. They're the ones that are utilizing the emergency room for medical care," Rowden said.
She said the Mennonites present a unique challenge because of their culturally restricted level of education.
"They don't typically educate children beyond sixth grade," Rowden said. "So you talk about people that really have difficulty comprehending complex health issues — this is a group that needs help."
According to a 2007 estimate by the Kansas Statewide Farmworker Health Program, there are likely 3,000 to 5,000 Low German Mennonites in southwest Kansas.
Rowden said what's needed are health education programs that address the education and language barriers. Examples would include classes that explain the importance of being vaccinated or how to manage chronic disease, such as diabetes or hypertension.
However, her 5,000-square-foot facility is out of room. "We certainly don't have enough space to provide all the services we would like to," Rowden said.
But by year's end, the health department will have twice the space thanks to a county-funded renovation project.
New space, more services
The $265,000 project to renovate an 11,000-square-foot building owned by the county is scheduled to start June 1.
The space being renovated for the health department is a soon-to-be-vacated 54-bed nursing home. On May 23, its clients will be moved to a new 80-bed nursing home.
The old nursing home has two wings, one of which is being renovated.
"We need this to capitalize on that prevention and health promotion piece that is so critical in people understanding how to take care of themselves," Rowden said.
For many, the term co-op evokes images of grain elevators, Depression-era workers stringing electric lines or maybe the more contemporary picture of a place where local-food devotees go to get a weekly helping of fresh produce.
But a group at work in Wichita has a different vision. They are working to develop a member-owned co-op that would provide thousands of Kansans with health insurance. And they want the coverage to be different from plans offered by traditional carriers.
Anne Nelson, associate director of the Central Plains Health Care Partnership in Wichita, an affiliate of the Medical Society of Sedgwick County, said the goal is to create a Kansas cooperative that offers individual and small business coverage that is both affordable and innovative in that it will emphasize patient-centered and preventive care.
“There will be a direct relationship with the people who are served by the products in the plan. If a product isn’t working based on consumer feedback, the consumer leaders (of the cooperative) can make changes,” Nelson said.
If the co-op does well financially, it would be required to use money not needed for claims or state solvency requirements to lower premiums or increase benefits.
Working with a small planning committee that includes health care providers, lawyers, actuaries, insurance experts and representatives of the business community, Nelson is preparing to apply for millions of dollars in federal loans to fund the launch of the nonprofit health insurance cooperative. She said she plans to submit the loan application this fall to the U.S. Department of Health and Human Services, which already has provided nearly $850 million in start-up and sustainability loans to health insurance cooperative in 10 states.
The loans approved earlier this year ranged from around $57 million to a cooperative in Oregon to nearly $175 million to the Freelancers Health Service Corporation, a union-affiliate co-op in New York. Midwest Members Health, which is planning to offer coverage to residents of Iowa and Nebraska, received $107 million.
“We don’t know yet what our application will be. But it’s a multimillion-dollar project,” Nelson said.
Money in health reform law
Creating more competition in the health insurance marketplace is one of the objectives of the controversial and still not-well-understood Affordable Care Act. The health reform law authorizes $3.4 billion in low-cost federal loans to start and help sustain at least one consumer-governed health plan in each state
In Pittsburg, the community health center so desperately needed more space that last year staff converted closets and a bathroom into offices.
But next year the number of patients the center sees is expected to grow 24 percent, said Krista Postai, chief executive of the Community Health Center of Southeast Kansas.
"And I have no place to put them," she said. "This building is totally and completely at capacity."
That should soon change.
By December 2014, using a $4.7 million federal grant, the center will nearly triple its space from 15,000 to 40,000 square feet.
The grant was announced today by the U.S. Department of Health and Human Services. It is part of more than $21.6 million awarded to five Kansas community health centers.
About 40,000 new patients will gain access to care thanks to the construction and renovation projects funded by the grants, according to HHS.
The funding stems from the Affordable Care Act, which authorized $9.5 billion to expand health services over five years and $1.5 billion for construction and renovation at community health centers.
“For many Americans, community health centers are the major source of care that ranges from prevention to treatment of chronic diseases," HHS Secretary Kathleen Sebelius said in a prepared statement. "This investment will expand our ability to provide high-quality care to millions of people while supporting good paying jobs in communities across the country.”
The grant amounts for the other Kansas health centers were:
■ $2.7 million for the Salina Family Healthcare Center in Salina.
■ $4.6 million for Hunter Health Clinic in Wichita.
■ $4.5 million for Konza Prairie Community Health Center in Junction City.
■ $5 million for PrairieStar Health Center in Hutchinson.
The grant funds were disbursed directly to the health centers, which are private, nonprofit organizations.
In Pittsburg, the new construction is set to begin in July and finish by December 2014, Postai said.
The center will then be able to expand most existing services as well as add optometry, physical therapy and speech therapy services. An estimated 8,200 additional patients will be able to access the center.
Plans are to add 42 positions at an average salary of $45,700 as a result of the expansion, center officials said.
The waiting room has been at capacity for years with more demand on it after one of the area's biggest employers was shuttered at the end of 2008. The wheel maker Superior closed as the auto industry crashed and the number of people near Pittsburg without insurance shot up from 12 percent in 2009 to nearly 18 percent in 2010.
"From the time we open, it is wall-to-wall people. We need space," Postai said. "You can only be open so many hours and you can only schedule so creatively. And our efficiency has been impacted by our lack of space."
Proponents in at least 15 states including Kansas are pushing their legislatures to license mid-level dental providers as a way to extend basic oral health care access to thousands who have none.
But those efforts are running up against a common obstacle: opposition from dentists.
Mid-level dental care was the topic today of a panel discussion at the Association of Health Care Journalists' annual conference in Atlanta.
Fear of the unknown is likely behind most dentists' opposition to mid-level providers, said panelist Michael Helgeson, a dentist in Minnesota. Alaska and Minnesota are the only two states that currently license mid-level dental providers.
"I think the fear that dentists have is that (mid-level providers) are going to be independent, they're going to get in deep and try to pull teeth that they're not able and licensed to pull, that they're going to get into lots of trouble. That's the fear that a lot of dentists have," Helgeson said.
He said licensing of mid-level dental providers in Minnesota ensures that doesn't happen. The key is oversight of their work by dentists, he said, which is required by the legislation passed in that state in 2009.
"They're not hanging up their own separate shingle. They don't on the nursing side either," Helgeson said of nurse practitioners, now commonplace in the U.S. since licensing began for them in the 1960s. "You can scour the literature and you won't find stories of people who went in for a throat culture and the nurse practitioner decided to do a tonsillectomy."
In Minnesota, dental therapists are required to have a management agreement with a dentist who oversees their work at remote sites sometimes via video telehealth connections. They are only allowed to practice in state-designated underserved areas, and their scope of work is limited. Further, Helgeson said, the dental therapists receive much of the same training as dentists, taking many classes side-by-side.
"I'm 100 percent confident that our dental therapists at Apple Tree know how far they can go, and when they're in a gray area we have telehealth," said Helgeson, whose nonprofit organization employs two registered dental therapists, as they're called in Minnesota. So far, there are 15 licensed in the state, he said.
Kevin Robertson, chief executive of the Kansas Dental Association, said dentists do not support the mid-level provider model simply because it would lower the standard of care to all patients.
"Why should the U.S. (or) Kansas lower the standard of care for oral care that is the gold standard for the world?" Robertson said.
Dealing with dental deserts
There's little dispute between dentists and advocates for mid-level providers that there is a pressing need to increase access to oral health care in Kansas.
At least 57,000 Kansans live in dental deserts, where there are no dental services and where the closest dental office is at least a half-hour drive from the resident's home, according to a report published last fall by the Kansas Department of Health and Environment and the University of Kansas Medical Center. KDHE officials project that number to increase as more dentists retire.
→ Continue reading at khi.org/midlevels.
In an ongoing disagreement over how to solve dental care access problems in Kansas, there is one thing no one disputes: the great need.
That need was on display in February when the Kansas Dental Charitable Foundation held its eleventh free clinic of the past decade. Known as the Kansas Mission of Mercy, the clinic was staffed by volunteer dentists in a vacant Walmart store in Kansas City.
Organizer Greg Hill said that patients began arriving at 8 p.m. the night before the clinic opened. They were able to spend the night inside the store. "By 5:30 a.m., there were 1,200 people in the building," Hill said.
At that point, the parking lot had to be closed, because no more patients could be treated in a single day— even with 165 volunteer dentists and many more hygienists and other support staff from all across the state. By the end of the two-day clinic 2,144 patients had been treated, adding to the total of approximately 20,000 patients served since Mission of Mercy began in 2002.
More than poor and uninsured lack access
Analysts have known for years that Kansas has a severe shortage of dentists, and that shortage is getting worse. The problem is greatest in rural Kansas, especially in the western part of the state.
To deal with the shortage, Fort Hays State University President Ed Hammond backs the idea of creating a mid-level dental provider — a person whose training and skills fall somewhere between those of a hygienist and a full-fledged dentist.
Hammond is keen to begin training those providers at Fort Hays State, but the proposal faces strong opposition from the Kansas Dental Association and has bogged down in the state legislature.
Hammond points out that it is not just the poor or uninsured who have trouble accessing dental care in western Kansas. Even a college president can have trouble.
"I can't get dental services where they accept our Delta Dental Blue Cross/Blue Shield plan," said Hammond. "As a state employee, I get — and pay for — dental insurance, but the dentists in western Kansas don't accept it."
Hammond says he's had to switch dentists three times to find someone who would accept his dental insurance. There are 13 primary care dentists in the Hays area, but Hammond says only a few accept Delta Dental.
"The shortage is impacting not just the indigent, not just the children. It's impacting all of Kansans in western part of the state," he said.
A report (PDF) published last fall by the Kansas Department of Health and Environment and the University of Kansas Medical Center counted 1,159 primary care dentists in the 105 counties of Kansas. However, roughly half of them are located in metropolitan Kansas City and Wichita. Add in Topeka and Lawrence, and more than 700 of the state's dentists are in just four communities.
Dental desert Western Kansas
Most counties in the western half of the state have only one or two dentists, if any. A dozen western counties, plus three more in eastern Kansas, have no dentist at all. Hammond said it's not hard to understand why dentists are reluctant to set up shop in frontier counties.
"The problem is, the people graduating from dental school are coming out with tremendous debt, and then they have to get a lot of equipment," Hammond said. "That raises the bar that their practice has to generate a certain amount of resources in order for it to make sense, and so they don't go to western Kansas and the smaller towns."
Hammond compared the so-called mid-level dental providers to mid-level medical providers who are already helping meet the need for primary care in rural Kansas.
"We train nurse practitioners that go out to the Hill Citys, the Atwoods, the various different communities throughout the state, and provide medical services. We're proposing to do the same thing with a mid-level professional in the area of dentistry," he said.
Hammond said Fort Hays State University is prepared to begin training this new class of dental providers as soon as the legislature approves the proposal. A coalition called the Kansas Dental Project submitted a plan last year. It would create a new type of provider with more training than a dental hygienist, but not as much as a dentist, called a Registered Dental Practitioner, or RDP. The new practitioners would be allowed to fill cavities and do simple extractions of children's primary teeth.
Dentists: Not a viable solution
But the Kansas Dental Association has fought this idea all the way. "The overwhelming majority of dentists are opposed to the registered practitioner model, and it's not like 99 percent. It's 99.9 percent," said Kevin Robertson, who heads the association.
Note: This story received praise from the Columbia Journalism Review this week: "Think of this particular turf war as a variation of rationing. You know, the denial or limiting of care that many claim does not occur in America, only in European countries with national health systems." Read their full write up here.
Three Kansas hospitals have laid off workers in the past two weeks, but that's not representative of overall industry trends in the state, according to analysts at the Kansas Department of Labor.
Labor economist Tyler Tenbrink said the state's unemployment rate for the health care industry remains very low at about 4 percent, compared to about 7 percent for all industries.
Unemployment claims in the health care and social assistance industry did jump at the onset of the recession in 2009, from about 500 to about 900 per month, he said.
"But that hasn't changed much since. Although volatile from month to month, the level has been steady," Tenbrink said. "The situation we've seen with the recent layoffs at hospitals, it's not typically an issue that the health care industry has. It's been growing quicker than other industries for a long period of time and we're projecting it to continue to grow quickly. It's not an industry that's having trouble."
This week, Hutchinson Regional Medical Center laid off 44 full-time and 11 part-time employees, about 5 percent of its staff. Last week, the hospital in Ottawa cut eight positions — about 3 percent — and McPherson Hospital cut five positions, or about 2 percent.
But Tenbrink said the statewide counts for job separations from hospitals have far outpaced unemployment claims, particularly since the recession began.
"That tells us that most of the people who leave their jobs are leaving voluntarily," he said.
Cindy Samuelson of the Kansas Hospital Association said she doesn't see a trend toward more layoffs but that hospitals everywhere were stepping up efforts to increase efficiency, sometimes by not filling empty positions.
"Efficiency in the delivery of health care is going to be essential for hospitals. Everybody is looking to make adjustments to right-size their organization — looking at staffing levels, costs, processes," she said.
Samuelson said the two main factors affecting hospitals in Kansas — and across the nation — were the ailing economy and reductions in Medicare and Medicaid payments.
"It's forcing hospitals to do due diligence, evaluating all things including staff levels," Samuelson said. "If they're going to continue to be a community hospital in today's world, they need to operate very efficient practices."
Kevin Miller, chief executive of Hutchinson Regional, said the economy and reimbursement rates had hurt his hospital's bottom line. But he said the main reason for the layoffs was to reduce a bloated staff.
"As a new CEO coming in — compared to my past experience — it was fairly evident to me that we had more staff than what we needed for our volume," said Miller, who came to Hutchinson in July after 33 years experience in health care administration in Ohio and Indiana.
→ Continue reading and see more data on health care employment trends at khi.org.