Sunday, August 6, 2017

Most public comments about changes to Medicaid proposal opposed it; comments of approval came with concerns

By Melissa Patrick
Kentucky Health News

More than 1,000 Kentuckians submitted comments about Gov. Matt Bevin's proposed modifications to the state's Medicaid waiver request, and almost all of them opposed the changes.

The modifications include stronger work and volunteer requirements, which would require Kentuckians who qualify for expanded Medicaid to work or participate in community service activities 20 hours a week or 80 hours a month. The original proposal called for a graduated increase in hours to the maximum of 20 hours after one year.

The revision also adds a six-month disqualification for those who fail to report changes in their work and employment status within 10 days of the change, and drops the expansion of a program that allows providers to give care to people who are presumed eligible for Medicaid, in favor of a "fast track" enrollment process that requires full enrollment and payment of premiums before coverage.

A cursory analysis by Kentucky Health News found that almost all of the submitted comments were against the modifications and the few that were favorable included concerns and qualifiers. Some comments were submitted more than once. Click here to link to the comments.

The Insure Kentucky Campaign, coordinated by Kentucky Voices for Health, collected and submitted comments from nearly 1,300 Kentuckians living in 108 of the state's 120 counties, according to a news release from the group.

Kentucky submitted its original proposal to the federal Centers for Medicare and Medicaid Services about 11 months ago, seeking a waiver from Medicaid rules. The proposal focuses on "able-bodied adults" who qualify for Medicaid under the program's 2014 expansion to those who earn up to 138 percent of the federal poverty level ($16,400 for an individual) under the 2010 Patient Protection and Affordable Care Act. The Trump administration is expected to approve the waiver.

Benefits would not change for pregnant women, children, the non-expansion population or the medically frail.

Kentucky has about 1.4 million people on Medicaid, with around 470,000 of them covered by the expansion. Bevin has said the state cannot afford to pay its share of the expansion, which is 5 percent this year, rising in annual steps to the reform law's 10 percent limit in 2020.

The updated proposal estimates that the changes would save taxpayers an additional $27 million over the next five years, bringing the state's total savings to $358 million by 2021, by having 9,000 fewer Kentuckians on Medicaid, 95,000 total. than if the changes weren't implemented.

Almost all opposed the changes

Many of the comments offered personal stories about how Medicaid and the expansion have improved their lives or improved the health of their friends and family. Almost all of them opposed the changes.

"Medicaid has changed so much in my family and my friends. They don't panic over getting sick. You don't know how stressful it is to be so scared of getting sick or being scared of having to make decisions about whether someone is sick enough to take them to the ER. Having Medicaid changes the way you feel all the time, knowing you have health insurance," one person said. (Comment #229621)

The commenter added, "These changes, all of them, they just make things more difficult. The 10-day reporting requirement and lock-out are pains in the ass. What is the point? It can't do anything but make things more difficult and make more people get kicked off Medicaid."

"The system we have now isn't perfect, but it is changing lives and needs more time before any changes are attempted!' said another comment (#229105).

"Ideally, program participants should be given at least 30 days to report changes; 10 days is not possible for most people. People would lose their jobs sitting at the DCBS [Department for Community Based Services] office trying to save their Medicaid! That isn't fair," said another (#229109).

"Some clients who have a persistent and severe mental-illness struggle to keep up with things like re-enrollment dates and deadlines and losing coverage would be detrimental," said a mental health therapist (#229197).

"Every one of these changes will impede access to treatment and therefore negatively impact overall health of Kentucky's citizens, especially its most vulnerable populations. None of my clients have extra money for premiums. Very few of my clients have reliable transportation, or phone minutes all month. I don't know how they are going to try to keep up with all this; I can't even keep it all straight. I don't know how they are going to manage these different accounts, or stay enrolled. This sounds like the goal is to make it so hard to get medicaid that people just don't and that's not right. People deserve health care," said a Bath County mental health therapist (#229477).

"The ability to obtain immediate access to Medicaid is very important; I totally disagree with change in the fast track!" said another (#229417).

Kentucky Voices for Health wrote: "We share Gov. Bevin’s goals of improving health outcomes and creating a more sustainable Medicaid program. But to accomplish that, we should start by reducing barriers to coverage, not increasing them. We should make the program easier to understand and use, not harder. And we should focus on encouraging people to use their coverage to improve their health, not enforcing new rules that are outside the scope of the Medicaid program."

The few supportive comments came with concerns

One commenter said, "I like the work requirement in spirit," but listed concerns about how the "community engagement" mandate will affect able-bodied caregivers who care for people who are not clearly defined as their dependent—such as extended family members; the challenges people have in finding employers that offers affordable health insurance; and the challenges they have, especially in the service and food industries, to get steady hours from week to week. "This requirement would mostly just hurt the people I think you are trying to help; it is maybe well intentioned, but not thought through," they wrote.

A retired home-health nurse said,"Yes, there should be accountability and responsibility," but asked: "Will there be job training programs, incentives for businesses to hire? Many of these people would work if they had opportunity. Losing their coverage for some would be detrimental to their health and the health of family. Will there be education programs to inform people of these changes if they are made? It would take a lot of people in every county to be available to help people, like Kynectors. Will there be a person to help upload documents? There is so much administration here, so much bureaucracy!"

Many questions

It was clear from the responses that Kentuckians still have many questions about the details of the new Medicaid plan. Here are just a few:

"I could not afford any medical bills without Medicaid. I'm on limited income. For the required work hours for medicaid, what about if you live in a area where there is no work to be found?" (Comment #229149)

"Will individuals who work jobs with varying wages that fluctuate over/under 138% on a regular basis, but annually remain under 138%, report changes? . . . Will residents of counties where SNAP [food stamps] work requirements are waived due to a lack of opportunity for work/volunteer hours (waived in 100 of 120 counties) also receive a waiver for the CE [community engagement] requirement, particularly since the modification states it is being modeled after the SNAP work requirement? . . . Will at least a one-time grace be offered for anyone who doesn’t understand the new guidelines, particularly those who are illiterate (English or any language) or have learning or language/cultural barriers/comprehension difficulties?" (part of InsureKY comments)

"Will mileage be paid for going to the work? Who will help find people jobs or pay to transport them if they don't have a car? Who will provide childcare or care for elderly relatives while "able bodied" people are trying to "earn" what should be their right as a Kentuckian: quality health care," asked one respondent (#229629).

"Is the state going to provide transportation to these volunteer positions? Is the state going to create volunteer positions? Is the state going to pay for the training for people? The management of the people? Is the state going to pay for the background checks? How about the child care?" asked another (#229637).

Several professional organizations oppose the changes

The Cystic Fibrosis Foundation, in addition to other concerns, said the 10-day reporting requirement was too short, and stressed that it should not be connected to any suggestion of fraudulent activity:

"The classification of failure to report changes in circumstance within 10 days as 'fraudulent activity' is a mischaracterization, as there may be people who fail to understand the process for completing redetermination paperwork or reporting changes that may impact eligibility. Using such terminology may discourage participation in the program by those fearful of inadvertently committing 'fraud' because they are unable to report changes within the 10 days." (Comment #266941)

Among other things, Centerstone , a behavioral health-care provider in seven Kentucky counties, said that while it supports the "overarching goal of encouraging engagement and responsibility for one's health care and increasing patient outcomes," added that the lock-out policy would "put undue burden on our consumers, specifically for consumers who fall just outside of the medically frail designation. For example, with patients struggling to overcome depression or take the first steps toward tackling addiction (employment, income, and daily functioning) may vary quite significantly. . . . Laborious reporting requirements would likely only result in a lapse in coverage, thus being locked out of evidence-based, preventative treatments that could otherwise keep an individual out of more costly inpatient facilities." (#272325)

Rich Seckel, director of the Kentucky Equal Justice Center, said in the InsureKY news release, "The waiver piles on complication after complication to coverage, with a startlingly punitive ‘lock out’ for not managing red tape—and no mention of accommodation for people who will find that hard. Instead of setting up consumers to fail, we should make programs work for working Kentuckians."

Some other organizations that sent detailed comments against the changes include: AARP (#269105), the Kentucky Center for Economic Policy (#269005), the American Congress of Obstetricians and Gynecologists (#268789), the National Health Law Program (#266877), the HIV Health Care Access Working Group (#270389), the American Diabetes Association (#269125), the Kentucky Equal Justice Center (#271369), Kentucky Voices for Health (#273677) and the Advocacy Action Network (in the Insure KY comments).

Several of the organizations offered research to support their claims as well as suggestions on how to move forward.

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