Proposed changes in Medicaid, especially making beneficiaries earn dental and vision benefits, alarm them and health advocates

Family Health Centers in Louisville built a dental clinic after Medicaid
expanded; under proposed changes people in the expansion would
have to engage in self-improvement activities to get dental or vision
benefits. (Angela Shoemaker photo, special to The Courier-Journal)

Gov. Matt Bevin's plans to change Kentucky Medicaid alarm people who are on the federal-state program, reports Deborah Yetter of The Courier-Journal.

The first example is Louisville construction worker David Thompson, who was able to get his first heath coverage in years through then-Gov. Steve Beshear's expansion of Medicaid under the Patient Protection and Affordable Care Act in 2014. "Thompson is hurrying to schedule dental and eye exams — care he said he urgently needs but realizes could be eliminated," Yetter reports.

Bevin's changes would initially eliminate basic dental and vision benefits for "able-bodied" adults in the expansion, which covers people with household incomes up to 138 percent of the federal poverty level. That makes a family of four with annual income of as much as $33,400 eligible for Medicaid.

For the first three years of the expansion, the federal government paid the full cost. Now states are paying 5 percent, and by 2020 that share will rise in annual steps to 10 percent, the ACA's limit — unless the ACA is changed, which also seems likely.

Bevin says the state can't afford the cost and expects the Trump administration to let him make changes that his aides say will leave Kentucky Medicaid with 85,000 fewer people on its rolls in five years than it would have without the changes. About 1.3 million Kentuckians are on Medicaid.

The governor and other state officials say the changes aren't just about saving money. Doug Hogan, a spokesman for the Kentucky Cabinet for Health and Family Services, said the plan will "better engage members in their own health, wellness, education and employability," as well as improving Kentuckians' health outcomes.

The plan would charge small, income-based premiums and co-payments for Medicaid coverage of people with incomes above the poverty line, and would require able-bodied people on the program to work, look for work or take job training unless they are a primary caregiver. They could earn rewards points to get dental or vision benefits by "passing a GED exam, completing job training or completing wellness activities such as stop-smoking classes.," Yetter notes.

"Advocates and public-health officials are increasingly concerned about what they believe will be an adverse effect on Kentuckians," Yetter reports. "Advocates worry consumers won't understand the complex changes to the program and, as a result, will lose coverage."

They especially worry about the "loss of dental benefits in a state with poor overall dental health," Yetter writes. She quotes Muriel Harris, associate professor of public health at the University of Louisville and board chair of Family Health Centers: "We're all very, very concerned. Those who have made the decisions are not considering the population we serve. It's just undermining any gains we have made in the past."

As for vision benefits, Yetter reports, "Kentucky optometrists have argued routine eye exams often uncover other serious health problems including diabetes, high blood pressure and eye disease that can result in blindness."

Yetter writes, "Collecting premiums and co-payments, tracking work or volunteer activity and managing the rewards accounts all will involve major technology systems changes and likely, hiring of outside vendors to manage such systems, advocates say. That adds to expense and potential complications, they said. . . . Kentucky is proposing monthly premiums of $1 to $37.50 per month, based on income and length of time enrolled in Medicaid. The longer people remain in Medicaid, the more it will cost, since Bevin's plan is aimed at pushing people to move to the commercial insurance market through employer coverage when available."

Most private employers in Kentucky don't offer health insurance to employees. The Kentucky Health Issues Poll has found that the percentage of Kentuckians on employer-provided insurance rose from 37 percent to 50 percent in 2014, but fell to 41 percent in 2015 and rose to 45 percent last year.