Medicaid revision will involve the old struggle between personal responsibility and how to care for the poor, C-J reporters write

Kentucky has been a national testing ground for federal health reform, but "may soon test something more fundamental – the age-old struggle to balance personal responsibility with the obligation to care for the poor," Laura Ungar and Chris Kenning report for The Courier-Journal.

Then-Gov. Steve Beshear, a Democrat, expanded the federal-state Medicaid program to cover people with incomes up to 138 percent of the federal poverty level. The federal government is paying the full cost of the expansion through this year, but next year states will begin paying 5 percent, rising to the law's limit of 10 percent in 2020.

New Gov. Matt Bevin, a Republican, says the state can't afford the full version of "Obamacare" and had ordered up a revised program that would be modeled on a year-old experiment in Indiana, which has different levels of coverage, requires co-payments and assesses premiums on an income scale.

"Participants are required to make monthly contributions ranging from $1 to $27," Ungar and Kenning note. "Those who don’t pay can be disenrolled, and anyone below the poverty level who fails to make payments is put into a 'basic' plan that has fewer benefits and requires co-pays for care. It also includes financial disincentives to repeated use of hospital emergency rooms, among other provisions. . . . The jury is still out on whether the approach saves money, promotes more responsible behaviors or adds barriers to accessing care, said Indiana University health researcher Kosali Simon."

Research of these questions in other states "tells us that any financial barriers you put in place for Kentucky’s lowest-income people can affect access to care,” Emily Beauregard, executive director of Kentucky Voices for Health, a coalition of pro-Obamacare groups, told The Courier-Journal. Other experts told the Louisville newspaper that "small co-pays and premiums typically don’t add up to meaningful revenue in state coffers – and may not even offset the cost of collecting them – with any savings likely coming from deferred care or fewer signing up for Medicaid," Ungar and Kenning write.

“A $10 co-pay doesn’t give the state much money, but it does have a big impact on beneficiaries,” Dr. Benjamin Sommers of the Harvard School of Public Health. Just what sort of impact is open to debate. Bevin says, “Having skin in the game is a big, big differentiator between whether or not the person has the dignity that goes with making decisions for themselves.” Health-reform advocates say complicating the system makes it harder to navigate, discouraging use of it, and becoming the main source of saving for the taxpayers.

But Darrell Patton, a Prestonsburg insurance agent who has helped people in Floyd County sign up for Medicaid, told The Courier-Journal that "skin in the game" is a good idea: "While some of Patton's clients couldn’t afford even small premiums, he said, too many work for cash and qualify for Medicaid while driving $40,000 trucks." Patton told the paper, “If you don’t have any kind of responsibility, sometimes you’ll seek the most convenient care – which is in a lot of cases the most expensive care,” such as the emergency room.

"Others say it’s not right to impose more costs on the neediest residents in a county where nearly one in three lives in poverty," Ungar and Kenning report. "Laneta Auxier, clinic coordinator at Mountain Comprehensive Care Center in Prestonsburg, said she agrees people should take responsibility for their care, but some patients can barely afford gas to get to the doctor, let alone co-pays."

"If Kentucky adopts an Indiana-style Medicaid expansion, Miller said, collecting co-pays will prove a challenge, based on his experience with the one Medicaid company he deals with that charges them. Doctors must document that they tried to collect, and the cost of sending out letters to those who can’t afford a $2 co-pay can be $5 or $10."