Health insurers again win lobbying battle with doctors and hospitals over prior authorization of procedures, treatments

By Melissa Patrick
Kentucky Health News

A bill to exempt health-care providers who have 90% or more of their claims approved from health-insurance companies' requirements for prior authorization of ceratin treatments has failed again. 

"Unfortunately House Bill 317 looks like it's dead," said its sponsor, state Rep. Kim Moser. "We tried in good faith to work out a compromise and we did not have the same reciprocation. And so, you know,  I'm not exactly sure why it didn't get a hearing." 

HB 317 was placed in House Banking and Insurance Committee and had two of its three required readings to be heard on the House floor, but it was never called up for a hearing. The last regular day for final passage of a bill is Thursday, March 28.

Moser said her bill is important because it would ensure timely treatment and care that has been prescribed by a person's health care provider. 

Rep. Kim Moser

"It's really about making sure that patients get the care that they need when they need it," she said. "I think that there is a way to find a process that expedites the care that patients can get – and this is it." 

Asked what concessions she had made with the insurance companies, Moser said, "We removed Medicaid, which was huge." 

That only left the 450,000 patients on the state-regulated plans, which would have provided a snapshot of whether the change would work, she said. 

"We weren't calling it a pilot, but you know, it would allow us to really look at how this helped, or if it didn't help at all," she said. " And, you know, that's all we wanted was to be able to see how it works and see if this is a process that, like I said, (would) expedite the care that patients can receive." 

Physicians say the system undermines their medical judgement, and increases their administrative costs. 

“The current prior authorization process leads to delays for patients, administrative burdens for physicians, and increased costs,” KMA President Dr. Michael Kuduk said in a Feb. 21 news release.  “It’s time for us to pass a common-sense solution that doesn’t harm our patients or overburden our healthcare system.”

Allowing exemptions based on past performance has been dubbed a "gold carding program." KFF Health News reported Feb. 12 that five states have passed some form of it: Louisiana, Michigan, Texas, Vermont and West Virginia, and the American Medical Association is tracing active gold-carding bills in 13 states. 

Kentucky won't be one of them, at least this year, despite the strong lobbying efforts of the Kentucky Hospital Association and the Kentucky Medical Association. Moser said this is the third year she has worked on this effort. 

Asked about the bill's failure, Cory Meadows, KMA's deputy executive vice-president and director of advocacy, issued a statement saying the groiup "is extremely disappointed by HB 317's failure to pass during the 2024 legislative session. KMA members expressed the need for changing the prior-authorization process used by insurers that limits, and in some cases prevents necessary health care to Kentuckians. Throughout these past several months, citizens from around the commonwealth also shared their own stories of how the prior-authorization system impacted their lives, clearly showing that nearly everyone except insurance companies see the need to change this system.

"We're encouraged by the overwhelming bipartisan support the measure received and remain extremely optimistic that with continued advocacy from our members and the public, as well as collaboration with lawmakers, this critical legislation, which proposes to streamline the prior authorization process and ensure patients have timely access to care will soon be enacted. Otherwise, insurers will continue to pocket the money that could make Kentuckians healthier."

The hospital association also expressed its disappointment. 

"Prior authorization is a huge burden on physicians and nurses at our hospitals. And you know, it's contributing to burnout. And so we definitely support legislation that would minimize that burden, as many as has been passed in other states, and we would love to see a pass here," KHA President and CEO Nancy Galvagni told Kentucky Health News. 

Health insurers say prior authorization prevents unnecessary care and ensures that the care meets the standards of best practice. 

The Kentucky Association of Health Plans, the trade group for companies selling health insurance in Kentucky, issued a one-pager in opposition to HB 317 that said, "Prior authorization stops inappropriate care and procedures and heads off dangerous drug interactions and duplicative or inconsistent care, providing a whole-person approach to each plan member’s care needs. Plans help protect against predatory behavior."

Asked about the bill's demise, Tyler Glick, KAHP spokesman, issued this statement: "The health mandate statement generated by the Department of Insurance says the bill would cost up to an additional $11.29 in health-insurance premiums per member per month. That means a family of four would pay an additional $541.92 a year. How is saddling taxpayers (Medicaid), state employees and teachers (Kentucky Employees Health Plan), and everyone else in the commercial insurance market with these costs sound policy? Kentuckians deserve better."

Glick added, "KAHP will continue working with all members of the General Assembly to promote affordability, expose waste and fraud, and provide safeguards to patients."

Moser said she's not giving up on this effort and will likely work on it during the interim.

"The burdens of prior authorization are not going away anytime soon," said Galvagni. "And I'm sure the issue will be back. And, you know, we look forward to continuing to work on that."

Kids Count County Data Book looks at the well-being of state's children, county by county, and has some 'warning signs'

Kentucky Youth Advocates graphic

By Melissa Patrick
Kentucky Health News

The 2023 Kentucky Kids Count County Data Book, which looks at the well-being of children in each county, serves as a guidepost for how Kentucky's children are doing. This year, it comes with some "warning signs."

"This year's Kids Count report, more than most, serves as a warning," Terry Brooks, executive director of Kentucky Youth Advocates, said at a Nov. 15 press conference to release the data book. "Candidly, it is not a house on fire, but it's certainly not good news." 

To support his warning, Brooks noted that only 46% of the state's kindergarteners are considered ready to learn, and that worsened in 105 of the state's 169 school districts. Also, two-thirds of fourth graders do not read at the national proficiency level, and 66% of eighth graders can't meet minimal math standards. 

Further, the report shows more Kentucky children are in foster care and fewer of them are being reunited with their families in 2020-22, compared to 2015-17. 

Brooks called the more than 200,000 Kentucky children living poverty a  "canary in the coal mine" because this number indicates where all of the other Kids Count data points are going. 

He also pointed to a decline in health-insurance coverage for children as an area of great concern. 

"Even areas where historically we've done better, there's warning signs," he said. "For instance, we still have a very high rate of kids who are covered for health insurance. That's the good news. The bad news is, well over half the counties in Kentucky are showing a decline in that." 

The percentage of Kentuckians under 19 who were covered by some form of health insurance in 2021 dropped just a bit, to 96.1%, when compared to 2016 when that rate was 96.7%. And, 97 of the state's 120 counties, or nearly 81% saw a drop in this coverage. 

The data book was compiled by KYA and the Kentucky State Data Center at the University of Louisville as part of the 33rd annual release of Kids Count, a national initiative of the Annie E. Casey Foundation to track the status of children in the United States.

Health indicators 

The County Data Book rates children's overall well being through 16 indicators in four major domains: economic security, education, family and community and health. The health indicators include smoking during pregnancy, low-birthweight babies, children under 19 with health insurance and teen births. 

Statewide, the report saw improvements in the percent of Kentucky births born to women who smoke during pregnancy, to 14.2% in 2019-21, down from 18.1% in 2014-16. 

Twelve Kentucky counties saw this number worsen: Ballard (17.9%), Bracken (30.1%), Calloway (14.2%), Crittenden (19.1%), Hickman (20.5%), Lawrence (27.6%), Livingston (21.3%), Lyon (21.4%), McCracken (14.4%), Trigg (19.6%), Trimble (26.6%) and Wolfe (34.8%). 

Smoking during pregnancy increases the risk of health problems for developing babies, including birth before full term, low birthweight, and birth defects of the mouth and lip. Smoking during and after pregnancy also increases the risk of sudden infant-death syndrome, according to the Centers for Disease Control and Prevention.

The percentage of low-birthweight babies in Kentucky stayed the same from 2014-16 to 2019-21, at 8.8%. The national average is about 8%.

A low-birthweight baby is defined as less than 5.5 pounds. The March of Dimes says babies born with low weight are more likely to have certain health conditions later in life, including diabetes, heart disease, high blood pressure, intellectual and developmental disabilities, metabolic syndrome and obesity.

Just over half of Kentucky's counties saw an increase in low-birthweight babies from 2014-16 to 2019-21. On the low end, five counties had rates undetr 6%: Carlisle (5.2%), Casey (5.8%), Lyon (5.2%), Oldham (5.7%) and Todd (5.7%). On the high end, two had rates of 15.3%: Robertson and Union. 

Fewer teenagers are giving birth in Kentucky. The state's rate was 22.8 per 1,000 females aged 15-19 in 2019-21, down from 31.7 in 2014-16. This rate has decreased steadily since 2014-16 when that rate was 31.7 teen births per 1,000 females aged 15-19. The highest rate, 54.5, is in in Menifee County. 

Twelve counties had higher teen-birth rates in 2019-21 than they did in 2014-16: Cumberland, 37.7 births per 1,000; Fleming, 34.7; Fulton, 33.7; Hickman, 37.5; Lee, 50.8; Logan, 32.4; Monroe, 41.2; Morgan, 43.1; Muhlenberg, 41.5;  Owen, 27.3; Robertson, 51.1 and Washington, 24.6. 

The report was made possible with support from the Casey foundation and other sponsors, including Aetna Better Health Kentucky, Kosair for Kids, Charter Communications and Mountain Comprehensive Care Center. 

The Kids Count Data Center provides easy access to county and school district data for about 100 indicators and allows the user to rank states, counties and school districts; to create customized profiles of the data; to generate customized maps; and to embed maps and graphs in websites or blogs. Click here to see your county's profile.

County Data Book from Kids Count measures the well-being of Kentucky's children, with county-by-county information

Pages from report show data for Menifee County. To enlarge any image, click on it.

By Melissa Patrick
Kentucky Health News

The annual Kids Count County Data Book on children's well-being ranks Kentucky 37th in the nation for the overall condition of its children. Since last year, the state improved in 10 of the 17 categories, including  fewer teen pregnancies and fewer women smoking during pregnancy. But the data show great disparities between counties and among children of color. 

This year's 2021 County Data Book focuses on disparities "caused by historic and systemic issues connected to the color of a kid's skin," many of which have been exacerbated by the pandemic, Terry Brooks, executive director of Kentucky Youth Advocates, said in an online news conference. 

"All kids face a long climb in their journey to adulthood, but kids of color have to climb a steeper hill due to longstanding inequities and specific barriers based on their skin color or country of origin," Brooks said in a news release. "When we invest in what all children need and tailor additional supports for children who face greater barriers, each Kentucky kid will have a brighter future." 

As an example, Brooks pointed to the disparities that exist around poverty. 

While the number of children in Kentucky in poverty has decreased, children in cities are more likely to be in poverty than those in rural areas, and Latinx and Black children are also more likely to live in poverty.

Brooks said the county-level poverty data in the report provides an opportunity for policymakers in Frankfort and Washington to take action on policies that impact poverty, such as child-care cost and accessibility, child tax credits and payday lenders, which he said "locate like cockroaches in areas of color in those urban centers." 

And it's not just about poor kids, Brooks said: "I have long presented the hypothesis, that unless and until we address childhood poverty, nothing else is going to move. That is the catalyst. It affects health outcomes; it affects education achievement; it affects family safety." 

In 2019, 20.9% of Kentucky's children lived below the federal poverty level, down from 25.9% in 2014. Oldham County had the lowest share of children in poverty, 4.8%, and Lee County had the highest, 44.3%. It is among 22 of the state's 120 counties in which more than one-third of children live below the poverty line, which in 2019 was $25,750 for a family of four. 

"With the cost of housing, food and transportation, most families need an income of at least twice the official poverty level to cover their basic needs," the report says.

It shows that poverty rates are much higher for Black (32%) and Latinx (30%) children and children of two or more races (33%) than white children (19%). Nearly one in four Kentuckians are children.

Another indicator of poverty is how much a family's income goes toward rent. In Kentucky, nearly half of  renters, 45%, spent at least 30% of their income on rent and utilities, a phenomenon exacerbated by the pandemic. Thirty-seven of the state's 120 counties either stayed the same or got worse on this indicator. 

The annual Kentucky Kids Count County Data Book, released Nov. 10 by Kentucky Youth Advocates and the Kentucky State Data Center at the University of Louisville is part of the 31st annual release of Kids Count, a national initiative of the Annie E. Casey Foundation to track the status of children in the United States. 

The Data Book provides information on the overall well-being of children in each county, through 17 measures in four areas: economic security, education, family and community and health. 

Overall, Kentucky saw improvements in 10 of the 17 indicators and did worse on four. Three of the indicators did not have baseline data for a year-to-year comparison.

Health indicators

Statewide, fewer babies were born to mothers who reported smoking at any point during pregnancy in Kentucky, and fewer Kentucky teens are having babies; but those rates vary widely by county. 

Statewide, 16.7% of Kentucky's babies were born to women who reported smoking during pregnancy in 2017-19, down from 19.8% in 2012-14. Still, 19 counties saw an increase in this rate since 2012-14.

Six counties (Warren, Daviess, Oldham, Jefferson, Fayette and Hancock) had smoking-in-pregnancy rates of 10% or less, and 13 had rates of 30% or more, all in Eastern Kentucky: Menifee, Lee, Harlan, Elliott, Jackson, Breathitt, Wolfe, Bell, Perry, Leslie, Clay, Owsley and Martin, the only county above 40%. 

Smoking during pregnancy increases the risk of health problems for developing babies, including birth before full term, low birthweight, and birth defects of the mouth and lip. Smoking during and after pregnancy also increases the risk of sudden infant death syndrome, according to the Centers for Disease Control and Prevention.

Kentucky continues to make improvements when it comes to teen births, which declined to 26.3 per 1,000 females aged 15-19 in 2017-19, from 37.7 births in 2012-14. But the rate is still much higher than the national rate of 16.7 per 1,000. 

There is a great difference among counties, ranging from a low of 7.1 teen births per 1,000 in Oldham County to a high of 62.3 in Powell County. 

Nine counties had higher teen-birth rates in 2017-19 than they did in 2012-14: Lewis, 54.4 births per 1,000; Harrison, 43.5; Monroe, 43.3; Ballard, 41.4; LaRue, 37.8; Breckinridge 32.4; Edmonson, 32.2; Bourbon, 32.1; and Hickman, 28.9.

The number of low-birthweight babies in Kentucky increased a bit, to 8.8% in 2017-19 from 8.7% between 2012-14. A low-birthweight baby is defined as less than 5.5 pounds.

The March of Dimes says babies born with low birthweight are more likely to have certain health conditions later in life, including diabetes, heart disease, high blood pressure, intellectual and developmental disabilities, metabolic syndrome and obesity.

More than half of the state's counties saw an increase in low-birthweight babies since 2012-14. The rates varied from a low of 4.3% in Spencer County to a high of 13.1% in Union County.

Babies born to Black mothers were most likely to have low birthweight, though that varied by community. In rural areas, Black mothers had 16.6 low-birthweight babies per 100 births, compared to 8.7 for white mothers and 6.4 for Latinx mothers.

"Strengthening access to quality health coverage before, during, and after pregnancy and closing gaps in use of programs like the HANDS home-visiting program would reduce disparities in critical birth outcomes for Black babies and mothers," says the report.

The report provides information on racial and ethnic disparities in each of the 17 indicators, and offers solutions for each category in hopes that the newly created Commission on Race and Access to Opportunity, made up of a group of bipartisan lawmakers and citizen members, will study and consider them. 

"We must acknowledge the racial and class disparities and address them head on," said Sen. Gerald Neal, D-Louisville. "We  should not equivocate in any way." 

Other key findings about Kentucky's children in the report include: 

• Even though 90% of Kentucky's high school students are graduating on time, compared to five years ago, 87 of Kentucky's 167 school districts got worse on this indicator. Further, only 46% of Kentucky's high-school graduates were deemed academically ready for college.
• Another gap is health-insurance coverage for the state's Latinx children, which is 91%, compared to 97% for Black children and 96% for white children. Overall, 95.7% of the state's children had health insurance, including Medicaid, in 2019.
• The most recent data shows that only 37% of Kentucky children in foster care reunify with their parent or primary caretaker, and this rate has dropped from about five years ago.
• The number of children in Kentucky's foster-care system increased to 53.7 per 1,000 children ages 0-17, from 39.2 in 2013-15. 
• Black parents are incarcerated at substantially higher rates than parents of other races in all Kentucky counties, with the greatest disparity in suburban counties, where 16.1 Black parents are in state custody per 1,000 adults, compared to 2.8 per 1,000 adults for white parents. 

Because of the pandemic, this year's data book is not able to provide comprehensive data for the most recent year for kindergarten readiness, fourth-grade reading and eighth-grade math scores. Instead, the report looked at the proportion of public-school students experiencing homelessness (3%), students with individualized education plans due to a disability (16%), and out-of-school suspension rates (9.6 suspensions for every 100 enrolled student). 

The report was made possible with support from the Casey foundation and other sponsors, including including Charter Communications, Louisville's Kosair Charities and Passport Health Plan by Molina Healthcare.

The Kids Count Data Center provides easy access to county and school district data for about 100 indicators and allows the user to rank states, counties and school districts; to create customized profiles of the data; to generate customized maps; and to embed maps and graphs in websites or blogs. Click here to see your county's profile.

Kentucky kids improve on some health measures, but many counties lag far behind; pandemic reveals a wealth of disparities

By Melissa Patrick
Kentucky Health News

When it comes to the health of Kentucky's children, who make up about one-fourth of the state's population, the good news is that most have health insurance, fewer teens are getting pregnant, and fewer of the state's women are smoking during pregnancy. The bad news is that the percentage of babies born at a low birth weight has inched up, and many chronic problems pose obstacles to children's well-being.

That's the upshot of the annual Kentucky Kids Count County Data Book, released Nov. 17 by Kentucky Youth Advocates and the Kentucky State Data Center at the University of Louisville. It's part of the 30th annual release of Kids Count, a nationwide initiative of the Annie E. Casey Foundation to track the status of children in the United States. The Data Book provides information on the overall well-being of children in each county, through 17 measures in four areas: economic security, education, community strengths, and health and family.

The report says Kentucky showed improvement in 11 of the 17 measures of child health, made no progress on three and declined on three. 

It shows fewer pregnant women in Kentucky are smoking during pregnancy, dropping from 20.4% in 2011 to 17.8% in 2016-18. But that's still nearly triple the national rate of 6.5%, according to America's Health Rankings.

In some counties, though, this problem is much worse, and got more so between 2016 and 2018. Eighteen counties had rates of 30% or more, led by Owsley County, with 45.3%, the only one with a rate over 40%. Also, 23 counties reported higher rates in 2018 than 2016. This problem correlates closely with income; Owsley is one of the nation's poorest counties; Oldham County, one of Kentucky's wealthiest, had the lowest rate, 9%.

Smoking during pregnancy increases the risk of health problems for developing babies, including birth before full term, low birthweight, and birth defects of the mouth and lip. Smoking during and after pregnancy also increases the risk of sudden infant death syndrome, according to the Centers for Disease Control and Prevention. 

Kids Count map; for a larger version, click on it.

Another measures that worsened in the latest report was the number of low-birthweight babies. The March of Dimes says babies born with low birthweight are more likely to have certain health conditions later in life, including diabetes, heart disease, high blood pressure, intellectual and developmental disabilities, metabolic syndrome and obesity.  

In 2016-18, 8.9% of Kentucky babies were born with a low birthweight, defined as less than 5.5 pounds. That was up very slightly from 8.8% in 2011-13. Again, those rates varied across the state with 58 of the 120 counties showing an increase, and 30 counties with rates higher than 10%. Carlisle County had the lowest rate, 5.6%, and Martin and Union counties had the highest, 12.7%. 

Kids Count map; for a larger version, click on it.

Kentucky continues to make improvements when it comes to teen births. It declined to 28.2 teen births per 1,000 females age 15-19 in 2016-18. That was 30% less than the 40.4 rate recorded five years ago. That said, it's still about two-thirds higher than the national rate of 17 births per 1,000. 

This measure also shows great differences among counties, ranging from a low of 7.5 teen births per 1,000 in Oldham County to a high of 67.3 in Powell County.

Seven counties had higher teen pregnancy rates in 2016-18 than in 2011-13: Lincoln (52.1 teen births per 1,000 females 15-19 in 2016-18); Nicholas (46.9); Edmonson (35.1); Elliott (57.3); Harrison (44.2); Hickman (29.1); and Breckinridge (36.1). 

Other key findings about Kentucky's children in the report include:

• Fewer children were living in poverty before the pandemic began, an improvement of 25.5% in 2013 to 22.3% in 2018; 107 of the state's 120 counties improved.
• 96.3% of Kentucky children have health insurance, and all 120 counties showed improvements in that. The report notes that disparities still exist when it comes to coverage, with only 91% of Latinx youth covered. 
• The number of children in foster care increased from 37.2 per 1,000 children ages 0-17 to 51.1 per 1,000; the number of children exiting foster care to reunite with their families dropped from 41% in 2012-14 to 37% in 2017-19. 
• The percentage of public-school kindergarteners who meet readiness-to-learn standards worsened in 78 of the state's 120 counties from the 2014-15 school year to 2019-20. Statewide, only about half of kindergarteners enter school ready to learn. 
• Because the K-PREP tests were not administered in Kentucky public schools during Spring 2020 due to the pandemic, this year's Data Book did not include the reading and math proficiency indicators. Instead it provided information on the proportion of students with an Individualized Education Plan due to having a disability and the percentage of students experiencing homelessness, which was 15% and 3% respectively.
• In a measure made more important by the pandemic, Kentucky ranks 40th in broadband access with 30% of students, and 35% of students of color, lacking adequate technology at home. 

This year's report also examines the impacts of what it calls "the dual pandemics" of covid-19 and systemic racial injustice on children and families. 

The report points to the disparities around case and death rates among Latinx and Black Kentuckians; the challenges that children with special needs face with remote learning; the challenges for children who are being raised by grandparents, who are at higher risk for the virus because of their age;  and the fact that children in low-income families are more likely to have parents with low-wage jobs that put their families at higher risk of contracting the virus, while being much less likely to have paid sick leave if they get ill. 

"The covid-19 pandemic reminds us once again that opportunities differ based on where you live, your family’s earnings, and the color of your skin," says the report. 

It lays out a plan of action to create "strong, equitable recovery" for all Kentuckians that includes responding to the impacts of trauma, prioritizing mental health supports, addressing the issues of low-wage workers, especially among families of color; strengthening access to health coverage and care for communities of color, bridging the digital divide for employment, education and health, prioritizing closing the gaps in educational achievement that has been exacerbated by the pandemic; and ensuring that families can meet their basic needs until the economy recovers. 

“The dual pandemics have shown us that the status quo was not working for many Kentucky kids and their families," Terry Brooks, executive director of Kentucky Youth Advocates, said in a news release. "We must use this opportunity to rethink and rebuild our systems in a way that achieves the vision of Kentucky being the best place in American to be young, regardless of the color of your skin, your zip code, or income level.”

The Louisville Courier Journal published five op-eds this week from people whose work is directly affected by the issues addressed in the Data Book. Click here for one that offers an overview of the data; click here for one that addresses child care; click here for one that addresses parental incarceration; click here for one that addresses health inequity, especially among Latinx populations; and click here for one that addresses the digital divide. 

The 2020 Kentucky County Data Book was made possible with support from the Casey Foundation and other sponsors, including Passport Health Plan by Molina Healthcare; Kosair Charities; Avesis Essential Benefits; and Mountain Comprehensive Care Center. 

The Kids Count Data Center provides easy access to county and school district data for about 100 indicators and allows the user to rank states, counties and school districts; to create customized profiles of the data; to generate customized maps; and to embed maps and graphs in websites or blogs. Click here to see your county's profile. 

Ky. campaigning in seven counties to get more of Black and Hispanic populations, hard-hit by covid-19, on Medicaid

Kentucky is launching a "1-2-3 No Cost to Me" campaign to get more Black and Hispanic residents enrolled in health coverage, Deborah Yetter reports for the Louisville Courier Journal. 

Image from Diversity Nursing Blog

The campaign aims to reduce racial disparities in health by adding eligible people to Medicaid, the federal-state plan for low-income or disabled people.

"We're very excited about this campaign," said Jackie Richardson, chief of staff for the state Cabinet for Health and Family Services, said at Louisville Mayor Greg Fisher's Aug. 11 press briefing. "We know that African Americans fall lowest when it comes to health outcomes, and this pandemic is no different." 

Fischer said the coverage could help ease some of the racial disparities highlighted by covid-19. In the Louisville area, 23% of residents are Black but account for about 27% of deaths from the disease, Yetter notes. 

Statewide, as of Aug. 15, Hispanics accounted for 13% of coronavirus cases though they are only 6% of the population. Black residents comprise about 8.5% of the population, but account for 14% of deaths and about 12% of cases.

"Early in the pandemic, when it appeared Black residents were suffering disproportionate rates of death and infection from the coronavirus, Gov. Andy Beshear pledged to try to expand health coverage for residents of color," Yetter notes.

The campaign, launched Friday, will focus on seven counties with the highest concentrations of minority residents: Jefferson, Fayette, Campbell, Christian, Madison, McCracken and Warren. Individuals must be legal residents to qualify for Medicaid, Yetter reports.

The campaign will include public-service advertisements and radio and television ads, billboards, bus stop ads, social-media ads, and notices in Black and Spanish-language newspapers. 

An estimated 20,000 Black and 34,000 Hispanic state residents lack health coverage, Health Secretary Eric Friedlander told Yetter.

Employer-sponsored insurance health plans in Ky. more costly in 2018; high premiums and deductibles leave many underinsured

By Melissa Patrick
Kentucky Health News

A recent analysis by The Commonwealth Fund, a foundation interested in the health-care system, shows that the overall cost of employer-sponsored insurance plans keeps going up, and families are spending more of their income on health care.

“The majority of people under age 65 in the U.S., 164 million, get their health insurance through an employer, and that insurance is less and less affordable for many of them,” Dr. David Blumenthal, president of The Commonwealth Fund, said in a news release. “Ensuring that everyone can afford health insurance and health care will require policy fixes and systemwide efforts to get to the heart of the health care cost problem: the exorbitant prices we often pay for health care in the United States.”

The analysis found that Kentucky families covered through employer plans spent on average, 13 percent of their yearly income for health coverage in 2018 -- or $7,471 in out-of-pocket spending. That was slightly above the national average of 11.5%.

That was a 3.1% increase from 2016, compared to a 4.4% jump in the national rate. But when you compare the state's average potential out-of-pocket spending in 2018 to what Kentuckians were paying a decade ago ($3,886), it's up 92%.

And because Kentuckians make less money on average than people in other states, they spend a larger share of their incomes on their premiums and deductibles. For example, in Kentucky, the median household income in 2018 was $50,247, compared to $61,937 nationally.

“Over the last decade, employer health-insurance premiums and deductibles have grown faster than workers’ wages. This is concerning, because it may put both coverage and health care out of reach for millions of people," Sara Collins, lead author of the study, said in the release.

The analysis of Kentucky empoloyer-based insurance shows that the premium cost for single-coverage plans saw the biggest jump between 2016 and 2018, from $1,290 to $1,633, or 12.5%. The rest of the nation saw a 3.8% increase for this measure.

Deductible costs for single coverage dropped 1.9%, to $1,833; deductibles for the combined average of single and family coverage dropped 3.2%, to $2,930; and premiums for family coverage increased 6.6%, to $5,382. Changes nationally were higher for the deductible costs, but lower for the premium cost.

Offering a bit of perspective, the Commonwealth Fund points out that high-deductible plans leave many people at risk of being underinsured, which is defined as having a deductible equivalent to 5% or more of their income. That said, a $2,930 deductible would leave many middle-class families in Kentucky underinsured, making it difficult for them to pay their medical bills and more likely resulting in skipping care because of the cost.

In general, the report says, employees pay about one-fourth of U.S. employers’ portion of the premium costs -- and that holds true in Kentucky. Employer-sponsored insurance premiums, which includes contributions from both the employer and employee, for single coverage in Kentucky in 2018 was $6,690 (up 7.8% from 2016) and $19,277 for family coverage (up 7.5% from 2016).

The researchers note that recent proposals to address the rising cost of health insurance include enhancing the affordability and cost protection of Affordable Care Act marketplace plans, allowing people with employer plans to buy coverage on the marketplace, or replacing private insurance with a public plan like Medicare.

The study used data from the federal Medical Expenditure Panel Survey. Researchers surveyed more than 40,000 business establishments in 2018, with an overall response rate of 67.8%. It looked at both premiums, the amount a person has to pay each month for their plan, and deductibles, the amount a person has to pay before an insurance company's payments kick in; and the size of the costs relative to the median income in each state.

Be wary of the complex pros and cons of Medicare Advantage plans during open enrollment through Dec. 1, columnist advises

By Trudy Lieberman

Community Health News Service

Along with crunchy leaves and pumpkins, fall brings a slew of advertising for insurance plans that fill the gaps in Medicare coverage.

Misleading and confusing messages continue to reach beneficiaries and those nearing Medicare age. To take myself as an example, I’ve received an invitation to a Medicare Advantage plan informational meeting. I’ve gotten a solicitation from my physician’s medical group offering a “zero-cost, no obligation way to review coverage” online or over the phone. The “review” is likely to bring a sales pitch for a plan.

A mailer from another plan offered “a friendly, money-saving Medicare Advantage Plan” that seemed to promise the moon: savings of up to $2,380 a year, maximum dental coverage of $1,500, and a $750 hearing aid allowance, a drop in the proverbial bucket considering the average cost of two hearing aids is about $4,500. One seller seemed to think I was on both Medicare and Medicaid and pitched a “special needs plan.” Since I wasn’t a candidate for such an arrangement, was the insurer trying to get in the door to sell a regular Medicare Advantage plan?

Too many people fall for those kinds of pitches during Medicare's open enrollment period, which runs through Dec. 1. Shopping to cover the gaps in Medicare is a task no one should take lightly. The stakes are too high.

Medicare is a fine program, but it was never meant to cover everything. It’s based on the old Blue Cross model of insurance common in the 1960s, where the company paid 80 percent of the medical bill and the patient paid 20 percent. An industry selling "Medigap" policies sprang up to cover the 20 percent, and deceptive sales practices plagued the business for years.

Congress ended that and standardized the coverage into 10 plans (now 11, including a high-deductible option) that give people a broad choice for covering what Medicare does not pay. If people bought Plan F or Plan C as their supplemental insurance, they were pretty much covered for most illnesses.

Beginning next year, however, new Medicare beneficiaries – those who turn 65 on or after Jan. 1, 2020 – won’t be allowed to buy Plan F or C. Congress wants more beneficiaries in Medicare Advantage plans, so it eliminated the option to buy the most comprehensive plans. Lawmakers wanted seniors to pay more for their care.

They can still buy Plan G, which offers the same protection as F except that it doesn’t cover the Medicare Part B deductible, which is $183 next year. People already on Medicare can still buy Plans F or C.

The goal is to push more people into Medicare Advantage plans, a private alternative that is a step toward privatizing the entire program. To move the process along, the government has overpaid insurers to provide the care, which enables them to offer inducements to join. About one-third of Medicare beneficiaries have moved to MA plans, so that strategy seems to be successful.

But does it come at a cost?

Serious questions have arisen about the overpayments the government has made using taxpayer dollars– overpayments that allow plans to offer gym memberships and even Apple watches, as monitoring devices, to new enrollees as one plan is doing. In September six Democratic senators wrote to the Centers for Medicare and Medicaid Services, noting that taxpayers have overpaid Medicare Advantage plans more than $30 billion over the last three years and that CMS has “taken little to no action to correct” the overbilling and overpayments.

Even more troubling, the letter also says that several other government agencies such as the Office of the Inspector General in the Department for Health and Human Services have raised “serious concerns” about Advantage plans that fail to meet needs of older adults and those with disabilities.

The letter raises questions about the kind of care beneficiaries are actually receiving, and notes that Medicare’s own audits have found “widespread and persistent Medicare Advantage performance problems related to denials of care and payment” that “threaten the health and safety of their members.”

Those are government watchdogs raising a red flag about problems getting care when you’re really sick and need good insurance.

Medicare Advantage plan advisers note that traditional Medicare does not put a limit on the amount a beneficiary must pay out of pocket each year, while Advantage plans do – $6,700 for in-network providers and $10,000 for those out of network. They usually don’t mention that a good Medigap policy will cover those amounts, but the premiums may be higher than for an MA plan heavily subsidized by the government.

The trade-off becomes what it does with all insurance: Pay now in the form of higher premiums, or pay later in the form of higher expenses if the worst happens. Insurers seldom mention that tough trade-off when they host those informational meetings for Medicare shoppers.

Health-care interests, using TV ads that hide who's paying for the air time, fight legislation to limit surprise or 'balance' billing; some ads come from air-ambulance companies, the big players

This ad claims the bill would help insurance firms and hurt patients.

Unknown people and businesses are giving millions of dollars to kill legislation nearing passage in Congress that would protect consumers from surprise medical bills. That's who's paying for those ads you're seeing on television. They're called "dark money" groups because they don't reveal their contributors.

"Pity the poor consumer trying to understand the coming congressional debate," writes journalist Trudy Lieberman, who considers patients' point of view. She says surprise bills have heaped "staggering amounts of debt ... on unsuspecting patients after they believed insurance had paid for their care. Those bills are growing rapidly and ensnaring more and more Americans in what has become one of the medical industry’s most unsavory business practices."

Lieberman notes a study just published in the journal JAMA Internal Medicine: "The number of surprise bills for both ER and inpatient admissions are rising. In 2010, about 32% of all ER visits resulted in surprise bills. In 2016, nearly 43% did. Surprise bills for inpatient admissions jumped from about 26% to 42% over the same period. What’s more, the average amount billed to patients for ER visits nearly tripled and the cost for inpatient admissions more than doubled."

With the TV ads, "the special interests that benefit from socking patients with additional bills" are trying "to convince consumers that any congressional efforts this fall to correct the surprise billing problem may actually harm patients," Lieberman writes. Noting the "Harry and Louise" ads that helped kill the Clinton health-care plan in 1994, she says "This kind of advertising works."

Lieberman says the industry is fighting hard because it fears "any kind of cost containment . . . something sorely needed, and bitterly fought for decades by the medical businesses whose incomes are at stake." 

The advertisers include a dark-money group called Another group, Doctor Patient Unity, which is targeting eight Republican senators, including Kentucky's Rand Paul and Majority Leader Mitch McConnell. KARE-TV in Minneapolis notes in an analysis that one of the bills "doesn’t set actually set rates for out-of-network procedures, but instead sets benchmarks for how much out-of-network providers can collect if a surprise bill shows up," Lieberman notes. "But in a TV ad that lasts a few seconds, how would the viewer be able to make that distinction?

University of Southern California research via Brookings Institution

"The air ambulance industry, which has gained notoriety over the last few years for its surprise billing tactics, too, has added its own ads to the confusing pile of persuasion aimed at the public," Lieberman reports. "According to OpenSecrets.org, the industry has spent hundreds of thousands of dollars on TV and radio ads" using the name Global Medical Response. "The scary message is that air medical services are at risk. More than 30 bases have closed this year, disappearing from rural communities that need these services the most, the ad says."

The ad urges viewers to contact Congress about the surprise-billing legislation. "It’s not hard to see that someone living in a remote rural area might just do that," Lieberman writes. "Never mind that in the last few years media stories have revealed how families have been financially devastated from air ambulance bills, and that state laws are ineffective in regulating this industry."

"And if all this isn’t confusing enough," Lieberman writes, "there’s yet another group, called the Coalition Against Surprise Medical Billing. It represents large employers, health insurance agents, and business associations like the National Business Group on Health." This coalition wants to eliminate "balance billing," the main type of surprise billing, when "a patient is involuntarily treated by an out-of-network doctor, and wants to require health insurers to reimburse out-of-network providers based on local market rates negotiated by local providers. That would avoid what it calls a cumbersome arbitration process, the approach preferred by the aforementioned doctors’ groups.

Steve Wojcik, vice president of public policy at the National Business Group on Health, told Lieberman, “I believe that the investor-driven physician staffing firms fear that if our preferences become law, their business model — go out of network and raise prices — is shot.” He added, “Everyone agrees on banning balance billing. The disagreement is over payment rates and processes for determining payment for out-of-network physicians.”

Lieberman concludes, "The scary TV ads flooding the airwaves from this group or that mask the real issue. It all comes down to money and who gets how much. . . . How this turns out is anyone’s guess right now, and it may be that Congress has been sufficiently spooked by the TV ads targeting its members that it will be too timid to pass any legislation addressing this growing problem. But there’s one thing we do know from the history of health care battles: The longer the legislative fixes twist in the wind and the attack ads run, the less likely any real protections for patients become."

Employer-sponsored health plans in Ky. saw modest cost hikes in 2017, but many people struggle with premiums, deductibles, etc.

By Melissa Patrick
Kentucky Health News

While much attention has recently been given to the number of people who sign up for health insurance on the federal exchange, the reality is that most people get their health insurance through their employer. A recent analysis by The Commonwealth Fund, a foundation interested in the health-care system, shows that the overall cost of employer-sponsored plans keeps going up.

“The vast majority of people under age 65 in the U.S., 152 million, get their health insurance through an employer, and many of them can barely afford to pay for it. Several bipartisan policy fixes have the potential to reduce health care burdens for workers and families struggling to afford the health care they need, while also making our health system work better for everyone," Dr. David Blumenthal, president of The Commonwealth Fund, said in a news release.

According to the analysis, 56 percent of people under 65 get their health insurance through an employer, while only 9 percent get their plans through a state or federal marketplace.

In Kentucky, the most recent open enrollment snapshot shows that 90,625 Kentuckians signed up for 2019 coverage on the federal exchange, compared to nearly 2 million who got coverage from an employer in 2017, according to the latest numbers reported by the Kaiser Family Foundation.

Average employee premium contribution, plus average deductible, as a
percentage of median state income in 2017. It shows Kentuckians spent
13 percent of their annual income on health coverage, or $7,136.

The analysis found that Kentucky families covered through employer plans spent, on average, 13 percent of their yearly income toward health coverage in 2017 — or $7,136 in potential out-of pocket spending. That was slightly above the national average of 12 percent.

That was only a 1.6 percent increase from 2016, compared to a 6.8 percent jump in the national rate. But when you compare the state's average potential out-of-pocket spending in 2017 to what Kentuckians were paying a decade ago ($3,886), it's up 84 percent.

And because Kentuckians make less money on average than people in other states, they spend a larger share of their incomes on their premiums and deductibles. For example, in Kentucky, the average household income was about $47,000 between 2016 and 2017, compared to $62,000 nationally.

“The cost of employer health-insurance premiums and deductibles continues to outpace growth in workers’ wages," Sara Collins, lead author of the study, said in a Commonwealth Fund news release. "This is concerning, because it may put both coverage and health care out of reach for people who need it most — people with low incomes and those with health problems."

The analysis also showed that premium cost for single coverage plans saw the biggest jump between 2016 and 2017, from $1,290 to $1,453, or nearly 13 percent. The rest of the nation saw a 6.8 percent increase for this measure.

But otherwise, the changes were modest.

Deductible costs for single coverage dropped 1.4 percent, to $1,878; premiums for family coverage increased .6 percent, to $4,764 and deductibles for the combined average of single and family coverage increased by .4 percent, to $3,138. National increases were much higher for each of these measures.

In general, the report says that employees pay about one-fourth of the employers portion of the premium costs — and that holds true for Kentucky. Employer-sponsored insurance premiums for single coverage in Kentucky in 2017 was $6,101 (up 6 percent from 2016) and $16,948 for family sponsored coverage (up 1.6 percent from 2016).

The researchers called on policymakers to address these rising health care costs and offered specific, detailed suggestions. "Policymakers will need to recognize that the increasing economic strain of health care costs facing middle-income and poor Americans is driven by multiple interrelated factors and will require a comprehensive solution," says the report.

The study used data from the federal Medical Expenditure Panel Survey. Researchers surveyed more than 40,000 business establishments in 2017, with an overall response rate of 65.8 percent. It looked at both premiums, the amount a person has to pay each month for their plan, and deductibles, the amount a person has to pay before an insurance company's payments kick in.

Four years into Obamacare, Kentucky's uninsured rate leveled out, and probably rose. Why? It depends on whom you ask

By Melissa Patrick
Kentucky Health News

In the fourth full year since the Patient Protection and Affordable Care Act was implemented, the percentage of Kentuckians without health insurance remained about the same, and probably increased. 2017 was the first year the percentage hasn't dropped since the program's inception in 2014, according to a new report from the U.S. Census Bureau, with data from its year-round American Community Survey.

In 2017, 5.4 percent or 235,000 Kentuckians had no health insurance, up slightly from 5.1 percent in 2016, a change that is statistically insignificant, because the poll's error margin was 0.3 percentage points. But chances are that the uninsured rate rose slightly.

Kentucky's uninsured rate was once relatively high, and the drop in it has been by some measures the greatest in the nation.

Before 2014, when Kentucky used the Patient Protection and Affordable Care Act to expand Medicaid to residents with incomes up to 138 percent of the federal poverty level, 14.3 percent of Kentuckians, about 616,000, didn't have health insurance. The expansion has added nearly 500,000 people to the Medicaid rolls.

Click on chart to view a larger version

“Medicaid expansion has been a game changer in the commonwealth. Because so many more Kentuckians now have coverage, people are getting healthier, hospitals are thriving and our economy is moving ahead,” Dustin Pugel, policy analyst for the left-leaning Kentucky Center for Economic Policy, said in a news release.

In general, the Census report shows that there is a clear divide in the uninsured rate among states that expanded Medicaid and those that haven't. In the 32 expansion states as of Jan. 1, 2017, the average uninsured rate was 6.5 percent, about half the 12.2 percent rate in states that haven't expanded.

Between 2016 and 2017, the rate did not significantly change in expansion states as a whole, and increased by 0.4 percentage points in non-expansion states.

Nationally, the share of Americans without health insurance remained the same in 2017, at 8.8 percent, or 28.5 million people.

The survey also found that 96.2 percent of Kentucky's children had health insurance in 2017, up from 93.6 percent in 2013. Children are covered by the Children's Health Insurance Program, a program similar to Medicaid in which the federal government pays most of the cost. Kentucky calls its part of the program KCHIP.

“Having health insurance means children are able to visit the doctor and the dentist to get the care they need to stay healthy," Terry Brooks, executive director of Kentucky Youth Advocates, said in a news release. "It means parents can take care of their health needs, so they can stay healthy and provide for their family. And, we know there is an undeniable link between parent’s coverage and their child’s coverage. As more parents receive coverage and care, so will their kids."

CommonWealth Magazine image

What the plateau in coverage numbers means depends on whom you ask.

Obamacare opponents blame the stalled progress in reducing the uninsured rate on rising premiums in the individual market, Rachel Roubein reports for Politico.

Supporters of the Affordable Care Act continue to be concerned about the Trump administration's ongoing attempts to repeal and "sabotage" the ACA, noting the shortened window to sign up for subsidized health insurance, huge cuts to the advertising budget and "navigators" who help people find an insurance plan, the removal of the individual mandate to have health insurance, and pending lawsuits to remove the requirement for coverage of pre-existing conditions.

Meanwhile, proponents are closely watching what will happen if Gov. Matt Bevin's new Medicaid plan is approved, after being vacated by a federal judge in Washington, D.C., just days before it was set to start on July 1.

The judge said federal officials had not sufficiently considered public comments about then plan, which were overwhelmingly against it, or the state's estimate that in five years its Medicaid rolls would have 95,000 fewer people with the plan than without it, partly due to noncompliance. The judge sent it back to the U.S. Department of Health and Human Services for more review.

The plan would require "able-bodied" Kentuckians who are not primary caregivers to work, attend school, take job training or volunteer 80 hours a month, or enroll in a drug-treatment program if appropriate. It also includes small, income-based premiums and lockout periods for noncompliance, among other things.

The Bevin administration is proceeding as if the plan will be approved, recently holding a hearing to discuss its regulations and continuing to hold stakeholder meetings to discuss it. At the Sept. 6 stakeholder meeting in Frankfort, asked how long the state expects the approval process to take, Kristi Putnam, deputy secretary of the health cabinet, said, "We don't think it will take a long time."

Bevin has said he will end the expansion if courts block his new Medicaid plan, and has issued an executive order putting the termination into effect six months after a final court judgment.

Health Secretary Adam Meier told lawmakers in August that the state is considering eliminating the expansion because Medicaid is facing a nearly $300 million shortfall. The new plan estimates that it would save $300 million over the next five years if it is allowed to proceed, with most of the savings a result of covering 95,000 fewer people.

State health official says Ky. is considering cutting nearly 500,000 people off of Medicaid because of a $300 million program shortfall

Health officials said the state is considering eliminating Medicaid coverage to almost 500,000 Kentuckians because the program is facing a nearly $300 million shortfall.

During a review of the 2018 fiscal budget and the outlook for 2019, Health Secretary Adam Meier told members of the legislature's Budget Review Subcommittee for Human Resources on Aug. 30 that Kentucky will be $296 million short by 2020, Adam Beam reports for The Associated Press. He added that dental, vision and pharmacy benefits are also on the table.

"That's certainly not anything we would want to do," Meier said, but "We also have a constitutional obligation to come in under budget. Unlike the federal government, we can't just print more money. We can't run a deficit."

Kentuckians at risk of losing coverage are the ones who gained it through the state's 2014 expansion of Medicaid, under the 2010 Patient Protection and Affordable Care Act, to those who earn up to 138 percent of the federal poverty level ( about $16,000 for a single person).

Medicaid is a federal-state funded program that covers about 1.4 million people in Kentucky, or about one-third of the state's population. The program costs about $11 billion a year, with most of it paid by the federal government. In Kentucky, the federal government pays about 70 percent of the cost for "traditional" Medicaid patients and 94 percent of the cost for the expanded population, an amount that will drop to 90 percent in 2020.

Before then-Gov. Steve Beshear, a Democrat, expanded Medicaid, the program was mainly limited to very poor pregnant women and children, disabled people and low-income elderly in nursing homes.

Asked what could be done to avoid the shortfall, Meier said, "The expansion population is an optional population."

Kentucky Democratic Chairman Ben Self told Beam that Meier "should be ashamed" for using those words. Meier told Beam after the hearing that "it was a technical term" used by the Centers for Medicare and Medicaid Services to describe populations that are not required to be covered.

Beam notes that the state is not required to cover people who qualify for Medicaid through the expansion. So far, 19 states have yet to do so. Virginia has passed an expansion, but it won't take effect until 2019; Maine voters have approved expansion, but it is in an ongoing legal battle because the governor won't allow it to be implemented; Nebraska is scheduled to vote on expansion Nov. 6.

The Bevin administration submitted a new  Medicaid plan to the federal government called Kentucky HEALTH (for Helping to Engage and Achieve Long Term Health) that was approved and set to go into effect July 1. The state estimated that the new plan would save the state $300 million over the next five years, with most of that savings a result of covering 95,000 fewer people.

However, a federal judge vacated Kentucky HEALTH just days before it was set to start, saying that federal officials had not sufficiently considered public comments about it, nor had they adequately considered the state's estimate that in five years its Medicaid rolls would have 95,000 fewer people with the plan than without it, largely for non-compliance with its requirement.

Since it was vacated, a 30-day comment period on Kentucky HEALTH that ended Aug. 18 overwhelmingly found that of the 9,397 unique comments, 8,438 or 96 percent were unsupportive, while only 373 or 4 percent were supportive, a ratio of over 20 to 1 against the waiver, according to an analysis done by the Kentucky Center for Economic Policy.

The new plan would require able-bodied adults who are not primary caregivers to work, attend school, take job training or volunteer 80 hours a month, or enroll in a drug-treatment program if appropriate. It also includes small, income-based premiums and lock-out periods for non-compliance, among other things. 

Gov. Matt Bevin has said Kentucky will end the expansion if courts block his new Medicaid plan,  and has issued an executive order putting the termination into effect six months after a final court judgment.

Beam reports that Meier told lawmakers the state had been counting on those savings to help avoid the shortfall. Meier added that the health cabinet will not eliminate the Medicaid expansion without first consulting the Republican-controlled legislature.

A group of hospital executives recently launched a campaign to encouraged lawmakers to expand the  health care tax to more providers, saying their plan would generate an estimated $372 million in 2020, Beam reports.

The group, called Balanced Health Kentucky, is motivated to save Medicaid expansion because it has significantly increased the number of people who are able to pay for their care, especially in rural hospitals, which had high rates of patients with no insurance prior the expansion. Since 2014, Kentucky's uninsured rate has dropped from about 14 percent to 5 percent, one of the sharpest drops in the nation.

Insurance expert advises: understand premiums, coverage, Obamacare subsidies and how much risk you want to assume

'Anyone buying health insurance this fall faces a daunting task: having to choose among multiple, often-complex options that offer widely varying degrees of protection," Trudy Lieberman of the Rural Health News Service reports in her latest column, syndicated to supporting organizations.

The new options include association health plans for small-business groups, short-term policies that may last from only a few months to a year (but can be renewed for three years in some states). "Then there are plans offered by church ministries that look like insurance but really aren’t," Lieberman writes. "Plus, multiple and complex options remain from the Affordable Care Act."

Trudy Lieberman, Rural Health News Service

Lieberman advises, "Before you comb through the fine print in an insurance policy, think about these major factors: The more you pay in premiums, the more you get in benefits. Many of the new options don’t have to cover all of the Affordable Care Act’s 10 essential benefits, and most insurance experts believe that in order to offer cheaper premiums, many of them won’t."

Low premiums and fewer benefits "may seem attractive," especially to older people who don't want to pay for mental-health and maternity coverage, Lieberman acknowledges. But the 10 essential benefits "also include prescription drug coverage, generous hospital coverage, emergency services, and rehabilitative services that are important to older people."

And there are pitfalls. Lieberman says some of the new policies "will limit hospital coverage to a certain number of days, or they might limit radiology services or drug coverage. The new so-called short-term policies will come with few if any regulations from the federal government or state insurance regulators."

Once you grasp the relationship between premiums and coverage, "The next big decision is how much risk you want to assume if you become seriously ill," Lieberman advises. "In other words, how much can you afford to pay out of pocket? For a large portion of Americans, the answer is not much. The Commonwealth Fund recently found that nearly half of working age adults could not pay an unexpected medical bill of $1,000 within 30 days."

Lieberman, who has covered health insurance for decades, writes, "Over the years, I’ve heard too many families say they are healthy, aren’t going to use the insurance, and might as well buy the cheapest policy possible – or none at all. I’ve interviewed many people who took that position only to end up later in bankruptcy court when unforeseen illness struck because they had no insurance and not enough money to pay the bills."

Once you understand your own situation, Lieberman says, "Look at the offerings on your state’s insurance exchange. Obamacare polices have gotten a bad rep almost since the beginning because they tend to be pricey for families that don’t receive an income-related subsidy to help cover the premium. About 87 percent of people who buy on the exchanges do get a subsidy."

And you may qualify for a second subsidy, cost sharing for people "with very low incomes who buy certain Obamacare policies. Those subsidies help pay for the deductibles and coinsurance that many of the policies require," Lieberman writes.

Lieberman asks, "What trade-offs are you prepared to make this year?" and asks you to tell her by emailing trudy.lieberman@gmail.com. For her entire column, and earlier ones, click here.

Hospital executives want lawmakers to tax other providers (and lower the rate) to help pay for Medicaid expansion population

The expansion of Medicaid to nearly 500,000 more Kentuckians "must be preserved," according to a group of hospital executives who launched a campaign to persuade legislators to expand the state tax on health-care providers to help pay for it, Deborah Yetter reports for the Louisville Courier Journal.

Norton Healthcare Vice President Riggs Lewis, the group's president, said at an Aug. 22 news conference in Frankfort that the expanded tax would raise enough revenue to fund the expansion, even as Medicaid costs continue to increase, Yetter reports. "Our group believes that conservative, comprehensive health-care tax reform can make that a reality," Lewis said.

According to Gov. Matt Bevin's administration, Kentucky's Medicaid budget is facing a $200 to $300 million shortfall over the next two years and that will nearly double when Kentucky's federal Medicaid match increases from its current 6 percent to 10 percent in 2020.

Yetter reports that the group, called Balanced Health Kentucky Inc., asks lawmakers "to consider expanding a tax now paid by hospitals, nursing homes and a few other health providers to others that don't pay, such as physicians, dentists and mental health counselors."

Lewis added that expanding this tax to other providers "would boost state funds available to draw federal money, which covers most of Kentucky's Medicaid costs," Yetter writes. At the same time, the hospitals would like to see the tax rate lowered. A chart from the Balanced Health website shows who pays what:

The federal government now provides about 80 percent of the $11 billion a year Kentucky spends on Medicaid. The state provider tax currently generates about $300 million a year; hospitals pay about $182 million of that

Board members of the group include executives from Norton Healthcare, Baptist Health, Appalachian Regional Healthcare, Manchester Memorial Hospital (in the hometown of Senate President Robert Stivers) and St. Elizabeth Healthcare, Yetter reports. An executive from Taylor Regional Hospital is also listed on their "volunteer team."

The expansion of Medicaid to people who earn up to 138 percent of the federal poverty level in 2014 under the Patient Protection and Affordable Care Act resulted in more Kentuckians being able to pay for their care, especially in rural hospitals, which had had high rates of patients with no insurance. Since 2014, Kentucky's uninsured rate has dropped from about 14 percent to 5 percent, one of the sharpest drops in the nation.

Yetter writes that Adam Edelen, who as state auditor examined Kentucky hospitals' finances prior to the expansion, said that Medicaid expansion had created a "reversal of fortune for many rural hospitals that had been struggling."

"It's been their salvation," Edelen said at the news conference. "You can't overstate how important the Affordable Care Act has been to rural hospitals."

Lewis acknowledged that any tax increase would have to be approved by lawmakers and said that the groups only suggestion was that it be "lower and broader," Yetter reports.

Interactive site shows potential effect in Senate President Stivers' district.

On a webpage titled "Who will lose coverage?" the Balanced Health Kentucky's website offers an interactive map of Kentucky that shows how many of the 500,000 Kentuckians who gained coverage through the expansion are in each county, the number of hospitals in that county and how many employees are hired by those hospitals. The map also breaks this information down by state legislators in both chambers, and by congressional districts.

Yetter reports that the campaign got mixed reviews.

Jason Bailey, executive director of the left-leaning Center for Economic Policy, told her that while his organization doesn't oppose a tax on other health providers, he pointed out that hospitals already benefit from a "freeze" that lawmakers placed on what hospitals must pay in 2006. He suggested that lawmakers consider lifting that freeze because hospitals' revenue has greatly increased since then.

"They aren't contributing more than they were 12 years ago and they're making a lot more money," Bailey said.

Sen. Morgan McGarvey, D-Louisville, told Yetter the proposal could lead to a way to permanently fund the expansion. "The alternative is unplugging it," he said. "You can't just take 500,000 people off health care."

But Jim Waters, president of the Bluegrass Institute, which promotes smaller government and lower taxes, told her that his organization would rather see Medicaid downsized by getting more people into jobs with health coverage. "I think the goal should be reducing that number," he said.

Emily Schott, a spokeswoman for the Kentucky Medical Association, gave Yetter a cautious statement: "The Kentucky Medical Association will review any research and data presented on provider taxes to determine the impact on physicians and their patients."

And though neither Senate or House Republicans, who hold majorities in their respective chambers, were ready to make a comment on the proposal, Yetter reports that Lewis said the group has been presenting their proposal to legislative leaders, who have shown interest, but no commitment.

Yetter writes that "the proposal comes at an uncertain time for Medicaid in Kentucky."

A federal judge vacated the state's new Medicaid plan just days before it was set to start on July 1, saying that federal officials had not sufficiently considered public comments about it, nor had they adequately considered the state's estimate that in five years its Medicaid rolls would have 95,000 fewer people with the plan than without it, largely for non-compliance with its requirement.

The state's new plan would require able-bodied adults who are not primary caregivers to work, attend school, take job training or volunteer 80 hours a month, or enroll in a drug-treatment program if appropriate. It also includes small, income-based premiums and lock-out periods for non-compliance, among other things.

Bevin has said Kentucky will end the expansion if courts block his plan, and has issued an executive order putting the termination into effect six months after a final court judgment.