Saturday, February 10, 2018

Friends and foes of new Medicaid plan agree it will cut program's rolls, but they disagree on why and how, and if that's good

By Melissa Patrick
Kentucky Health News

National experts and some Kentuckians say requiring the "able-bodied" in Medicaid to work, and most in the program to pay premiums, will result in fewer people getting health care from it. One state representative says it's all about saving money; Gov. Matt Bevin says it's not.

One of those Kentuckians is Ronnie Stewart, 62, of Lexington, one of 16 Kentucky Medicaid beneficiaries suing the Trump administration over the changes it allowed in the state. The lawsuit alleges that the new plan violates the 1965 Medicaid Act because it will reduce delivery of health care to poor people who need it.

Stewart, who worked for years as a state social worker, told John Cheves of the Lexington Herald-Leader that his experience leads him to believe that the plan is designed to knock people off the program, not improve their health, as Gov. Matt Bevin says.

"He’s just trying to set up roadblocks so he can trip people up and then knock them off Medicaid to save money. That’s all there is to it,” said Stewart. “When you charge a premium, some people can’t pay it, so off they go. When you make people file a report every month, some people aren’t going to make the deadline, so off they go. It’s all about putting up roadblocks.”

The state's request for the changes estimated that with them, the Medicaid rolls will have 95,000 fewer people in five years than without them, partly because of "non-compliance" with the program's requirements. Medicaid covers 1.4 million Kentuckians, about 480,000 of them on the expanded version under the federal health-reform law. A list of enrollment by type and county in January is at

Bevin's plan, called Kentucky HEALTH, was the first in the nation to be allowed to require most "able-bodied" Medicaid recipients to work or volunteer 80 hours a month to keep the health insurance.

Cheves writes that the plan also has other "hurdles" such as monthly reports of employment and income; annual re-enrollments; and a list of activities to complete in order to get dental and vision benefits, which are being dropped from Medicaid's basic coverage.

"Missing a payment or notification could trigger a six-month lockout on basic health coverage," Cheves notes. "Missing the enrollment window could mean waiting nine more months for the next opportunity."

"Health policy experts say Kentuckians are likely to fall off the Medicaid rolls because of the paperwork obstacle course," Cheves reports. "Someone juggling a low-wage job, children and the usual turmoil associated with poverty is unlikely to have time for regular check-ins with Medicaid officials, even assuming they have reliable internet access or transportation to a state office building in their community."

Laura Dague, an economist who studies Medicaid policy at Texas A&M University, told Cheves that research shows that even small premiums discourage enrollment.

“You would think the value of the program would outweigh the cost of paying $10 a month," Dague said. "It’s sort of unexpected that small premiums have such a large effect. They have almost the same effect as large premiums. The implication is that part of the effect of premiums is to basically increase the filing and paperwork demands on the enrollee, and that itself is what is having an effect.”

This was demonstrated in Indiana, which implemented monthly premiums of $1 to $27 for its expansion population in 2015. By October 2017 about 25,000 adults had lost their coverage for failure to make their payments, according to Kaiser Health News. Indiana officials estimated, based on surveys of recipients, about half of those who were dis-enrolled found another source of coverage, most often through a job.

At a Feb. 5 news conference, Bevin said that no one was going to be kicked off of Medicaid, and that there would only be two reasons Kentuckians would lose their coverage -- and both of those reasons were good. "Number one, because they don't need it anymore, which is great," he said. "Or number two, because they don't want to do anything in exchange for something of value, and that's also good." 

In an op-ed for the Louisville Courier Journal, state Rep. Tom Burch, a Democrat who was the longtime chairman of the House Health and Welfare Committee, wrote: "Let’s be honest: Kentucky HEALTH, as the waiver is called, is designed to save the state money, not improve health outcomes for poor and low-income Kentuckians. The savings stem from fewer enrolled participants . . . and not all of these participants will get full-time jobs that come with health benefits. This waiver will also increase bureaucratic red tape for those least able to unravel it."

The Bevin administration disagrees, and told the Herald-Leader that the monthly check-ins will be “streamlined and automated” for people using the internet and those visiting a state office, and that the low monthly premiums "are not intended to be a barrier," but instead will replace co-payments and make the process easier.

"By increasing personal involvement in health-care decisions, members gain skills for long-term success and are empowered to take an active role in their day-to-day health care decisions,” said Adam Meier, Bevin’s deputy chief of staff for policy.

Cheves writes, "In Indiana, data show that Medicaid recipients in the monthly premium plan are more likely to obtain preventive health care, stick to their prescription drug regimes and avoid the emergency rooms for unnecessary visits than Medicaid recipients in the traditional plan that charges co-payments, Meier said."

As for the work requirements, Paige Winfield Cunningham of The Washington Post writes that Medicaid managed-care companies aren't concerned about the new rules because they will affect so few people.

Jeff Meyers, president of Medicaid Health Plans of America, acknowledged that the work requirements will likely result in a drop in enrollment, as it did when they were introduced to welfare in the 1990s, but he expects the drop to be minimal.

“We’re not hyperventilating that millions of people will get thrown off the rolls,” Meyers told Cunningham. “We just want to make sure as states do this, they understand there is a cost involved.”

Tom Miller, a health-care fellow at the conservative American Enterprise Institute, told Cunningham that he estimates work requirements might affect up to 20 to 30 percent of the Medicaid population.

Nationally, most Medicaid beneficiaries work, mostly at low-wage jobs that don't offer health insurance, and those that aren't will fill one of the exemptions for the work requirements according to the Kaiser Family Foundation. Kentucky figures indicate likewise for the state.

Bevin said when he was running for governor in 2015 that some able-bodied Kentuckians were choosing to stay home and play video games, and not working, in order to qualify for Medicaid.

Emily Badget and Margot Sanger-Katz of The New York Times recently wrote that the idea that "able-bodied" people "don't want to do anything for something of value" is tied to a long history of thinking that separates the deserving and the undeserving poor. The authors say "able-bodied" is a political term that has long been a descriptor in the food stamp and welfare programs.

“Within that term is this entire history of debates about the poor who can work but refuse to, because they’re lazy,” said Susannah Ottaway, a historian of social welfare at Carleton College in Minnesota. “To a historian, to see this term is to understand its very close association with debates that center around the need to morally reform the poor.”

Doug Hogan, spokesman for the Cabinet for Health and Family Services, disagreed with this depiction of the word "able-bodied."

The phrase "Able-bodied adult is borrowed from existing nomenclature" used in other programs, Hogan said in an email. "This is especially important given the high overlap in enrollment between programs. It has not been used in Medicaid because prior to Medicaid expansion, there were few who would have met this definition. It is not intended to have a negative connotation. It is intended to describe the population as clearly as possible—nothing more, nothing less."

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