Patients confused, providers worried, Democrats and advocates upset over decision to limit Medicaid dental and vision benefits

The end of dental and vision benefits for 460,000 Kentuckians on Medicaid caused some pregnant women and children to be denied care because of a reported glitch in the system. It also prompted complaints from Democrats and others that the move violated federal law.

The Bevin administration blamed the cuts on a federal judge's ruling that vacated the state's new Medicaid program, which was to launch July 1. Judge James Boasberg of Washington, D.C. sent the plan back to the U.S. Department for Health and Human Services for review, ruling that Secretary Alex Azar had not fully considered the state's projection that in five years the Medicaid rolls would have 95,000 fewer people with the plan than without it.

The state's action mainly affects Kentuckians who gained access to Medicaid when then-Gov. Steve Beshear, a Democrat, expanded it in 2014 to those who earn up to 138 percent of the federal poverty level, under the 2010 Patient Protection and Affordable Care Act.

Deborah Yetter of the Louisville Courier Journal reports, "Dentists have been forced to turn away children and other patients who are mistakenly showing up in the state's computer system as having lost coverage," including pregnant women and disabled adults who are clearly exempt from the cutoffs.

Yetter offered examples, including a Floyd County dentist who said he turned away at least 10 children since Monday for lack of Medicaid coverage; another in Louisville who said her patients were coming in for appointments with no idea they had lost their coverage and couldn't pay the $30 required for those without insurance; and another in Pikeville who said he had had to cancel multiple appointments for people who had lost coverage but should have been exempt.

The Kentucky Oral Health Coalition says that they too have heard from multiple KOHC dental providers across the state that the state's changes to the dental program have resulted in the denial of routine dental care to eligible children and pregnant women. 

"Due to a shortage of dentists who accept Medicaid in Kentucky, particularly in rural areas, we know that some families travel several hours just to get to a dental appointment," KOHC writes in a statement, adding that summer vacation is typically a prime time for caregivers to schedule these visits. "This timing adds to the urgency. We cannot allow families to show up only to be turned away and miss their opportunity to access the dental care they need to stay healthy." 

Doug Hogan, spokesman for the state Cabinet for Health and Family Services, told Yetter that he needed more specifics to determine if people were being wrongly classified or if providers had gotten incorrect information. "According to system checks, eligibility is being correctly applied to children and pregnant women," he said, adding that those with concerns can call 1-800-635-2570.

Dental providers who serve the poor are worried

Jennifer Hasch, a dental hygienist at the Shawnee Christian Healthcare Center, which serves people regardless of income in west Louisville, at a July 2 news conference in Louisville with local Democrats, said that 70 percent of their patients were on Medicaid, with an estimated half of those in the expansion population, Joe Sonka reports for Insider Louisville.

Photo from Family Health Centers website

Hasch added that when poor people can't see a dentist, they go to the emergency room, which she said was at least three times as expensive as a normal dental visit. She later told Sonka that the abrupt end of dental benefits for so many had created much uncertainty about who did or did not still have dental coverage.

Bill Wagner, CEO of Family Health Centers, federally qualified clinics that treat patients regardless of income, told Louisville's Metro Council last month that the center feared 8,400 of their patients could lose Medicaid coverage over the next five years under the plan.

"Wagner added that with the dramatic increase in patients covered by Medicaid expansion over the last five years, the city has lowered its annual amount payments to the center for uncompensated care by roughly $1.1 million," Sonka reports.

While speaking at the news conference, Wagner  said that the clinics likely will have to start charging a basic fee of $30 per visit, an amount some can't afford, Yetter reports.

On Thursday, July 5, the Kentucky Rural Health Association sent out a list of codes from the state Department for Medicaid Services that are to be used for Medicaid members who are listed under the "Alternative Benefit Plan" created for the expansion population.

What's it all about?

Medicaid is a joint state and federal health insurance program that spends $11 billion a year to cover about 1.4 million Kentuckians, more than 600,000 of them children. Before the expansion, it was mainly limited to very poor pregnant women and children, disabled people and low-income elderly in nursing homes.

Bevin and his administration have long argued that any money spent on the "able-bodied" expansion population takes money away from those who are truly in need. Others, including Judge Boasberg, hold that "where Medicaid's fundamental purpose and statutory protections are concerned, expansion beneficiaries stand on equal footing with 'traditional' populations," Sara Rosenbaum writes for The Commonwealth Fund.

The plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long-Term Health," included requirements for work, volunteering, job training or drug treatment; monthly reporting; lock-out periods for failure to comply; and small premiums and co-payments based on income.

Under Kentucky HEALTH, people covered by the Medicaid expansion were to earn dental and vision benefits by participating in certain activities, such as accessing preventive-care services or participating in job training. (Most people on the expansion work.)

Separately, the state moved to end the free benefits for the expansion population starting July 1 because of Boasberg's ruling.  "There is no longer a funding mechanism in place to pay for dental and vision services," the health cabinet said in a statement. 

MaryBeth Musumeci, associate director for Medicaid and the uninsured at the Kaiser Family Foundation, told Lisa Gillespie of Louisville's WFPL that it’s perfectly legal for the state to limit dental and vision benefits, but that it could also restore them.

“The court’s decision is not prohibiting Kentucky from continuing to offer vision and dental as they have prior to the waiver,” Musumeci told Gillespie. “Those benefits continue to be optional and they could include them in the benefit package, or not.”

State officials said they limited the benefits to reduce expenses in Medicaid, but that was illogical, the Lexington Herald-Leader said in an editorial, "because emergency-room visits for dental problems will increase," and are three times as expensive as a dental visit. The editorial noted that administration "officials have said they can’t say how much eliminating the dental and vision benefits would save or cost and that fewer than 10 percent of Medicaid recipients use those benefits."

The elimination of vision and dental coverage does not apply to pregnant women, children, individuals who are considered medically frail, former foster youth up to age 26, and groups covered by Medicaid before the expansion, including parents who make below 28 percent of the federal poverty limit, Gillespie notes.

Louisville Democrats voice outrage over cuts

Democratic politicians gathered Monday at a news conference in Louisville to blast the Bevin administration's handing of the matter.

At a news conference, U.S. Rep John Yarmuth of Louisville called Kentucky HEALTH illegal, and said it was driven by Bevin's "ideological motivations," Sonka reports.

“Medicaid is not a work program," Yarmuth said. "It is not a program designed to familiarize people with commercial health insurance, as the governor has said. It is a program to provide medical coverage to the poor and working poor."

Rep. John Yarmuth and other Democrats spoke against the
Bevin administration's cuts to dental and vision benefits for
some on Medicaid. (Photo by Joe Sonka, Insider Louisville)

Yarmuth added that if Bevin ends the expansion, as he has said he would do if courts ultimately block the plan, it would cost the state an estimated $30 billion in economic activity for hospitals and providers over the next 10 years, while the state would pay only 10 percent of that, because the federal government covers the rest of the expansion costs, Sonka reports.

Yarmuth told Nick Storm that he had asked the Centers for Medicare and Medicaid Services on July 2 if Kentucky had cut off these dental and vision benefits legally, and they told him they didn't know.

Nick Storm of Spectrum News reports that former state auditor Adam Edelen, who is considering the 2019 race for governor, also spoke at the news conference, saying “What we need is leadership in Frankfort that understands it’s not that the poor are not working hard enough, it’s that the work they’re doing doesn’t pay enough.”

Rep. Joni Jenkins suggested that patients with unresolved dental pain created a "gateway to addiction," which is "like throwing gasoline on our opioid epidemic here in Kentucky."

Sen. Gerald Neal said that he and Sen. Morgan McGarvey plan to file a bill in next year’s legislative session to require that all Medicaid recipients in the state have dental and vision benefits.

So what's next?

While the state and federal governments have been expected to appeal the court decision, Rosenbaum reports that the Trump administration could also decide to rework Kentucky's plan, which she writes "would seem to be the prudent choice, since the decision leaves open the door to Medicaid work experiments, and since multiple state proposals are potentially waiting in the wings."

Eight other states with Republican governors (Arkansas, Arizona, Indiana, Kansas, Maine, New Hampshire, Utah and Wisconsin) and one state with a Democratic governor (North Carolina) have asked the Trump administration for the green light to enact similar requirements as had been requested in Kentucky HEALTH.

The Associated Press sums up the judge's fundamental question as this: "Are poverty programs meant to show tough love or to help the needy?"

Local coverage

Bobbie Curd of The Advocate Messenger in Danville offers an example of how to localize this story. She notes that Boyle County has 5,700 people on Medicaid, equal to 20 percent of the county's population. (County totals of people on Medicaid, the expansion and other categories are at http://www.uky.edu/comminfostudies/irjci/MedicaidenrollmentbycountyJune%202017.xlsx.)

The director of the Boyle County Health Department, Brent Blevins, told Curd that he, and many others weren't told of the limitation of dental and vision benefits.

“If we don’t have a good program or option for those people to pick up quickly, you’ll have people going without coverage for extensive lengths of time,” Blevins said.

Blevins added that it "would be a significant issue in our community" if 1,000 or even 500 people in Danville lose their ability to afford dental and vision care.