A Battle Over Medicaid Coverage Takes Center Stage in Kentucky
The latest battle over Medicaid coverage in Kentucky has left advocates, providers, and patients in a seemingly perpetual state of limbo as benefits and new requirements are being contested in court, and as federal approval for a state waiver looms.
Since being elected, Governor Matt Bevin (R) has made rolling back the Medicaid expansion enacted by his predecessor three years ago a key priority. Bevin and the Republican-controlled state General Assembly have tried to strip dental and vision coverage and implement work requirements for Medicaid recipients under the proposed 1115 waiver.
“What is it we’re looking to change is, we simply want, for those that are able to be engaged in their own health outcomes, we want them to be, because there’s dignity and self-respect that is offered to people through the ability for people to do for themselves,” Bevin told the PBS NewsHour in January. “Human beings want to be treated with dignity and respect. They do. And we’re going to give them that opportunity.”
So far, those efforts have been thwarted by advocates and two federal judges. U.S. District Judge James Boasberg included thousands of comments from Medicaid recipients in his final decision in June that effectively halted the proposed changes to the program, primarily the enactment of work requirements. Boasberg said officials did not adequately consider what impact the changes would actually have on recipients’ ability to access healthcare coverage, which is a central aspect of Medicaid.
On Monday, U.S. District Judge Gregory Van Tatenhove dismissed Bevin’s lawsuit that sought to validate his administration’s proposed Medicaid changes, saying the administration failed to establish proper jurisdiction to bring the case before a federal judge.
People impacted by Medicaid must now wait for the Center for Medicare and Medicaid Services to review the Bevin administration’s new proposals and thousands of additional public comments before making a final decision about whether or not Kentucky’s waiver can stand.
The battle has focused mainly on work requirements, which would force Medicaid recipients to prove they’re actively employed or volunteering, and that they have worked more than 80 hours a month to maintain coverage. If they do not meet these requirements, or fail to keep their online records updated, they could be locked out of coverage for six months.
“The amount of red tape the waiver creates is disturbing, particularly coming from an administration that claims to believe in red tape reduction,” said Angela Koch, State Outreach and Education Director at Kentucky Voices for Health (KVH).
KVH is a statewide advocacy organization that informs citizens about healthcare coverage options and pushes for more equitable state healthcare policy. The organization has been trying to stay abreast of the ways in which Medicaid coverage will change if Kentucky’s 1115 waiver is approved, but Koch says it’s been “nearly impossible.”
“It’s been a very reactive period for advocates and those on the ground. We’ve had very little ability to plan,” Koch says.
Adam Meier, Kentucky’s secretary of the Cabinet for Health and Family Services, defended the state’s plan after the June court defeat as an “an innovative, thoughtfully crafted program that will strengthen Medicaid by engaging beneficiaries in their own health outcomes.”
Meier added: “We will fight to preserve these opportunities for our citizens so that we can proceed with the only viable path forward for expanded Medicaid in Kentucky.”
Medicaid in Kentucky covers people who are living at or below 138 percent of the Federal Poverty Level, which is about 1.4 million Kentuckians. State calculations suggest that nearly 100,000 people would lose coverage under the 1115 waiver, dubbed “Kentucky HEALTH” by the Bevin administration.
KVH reports there are 18 proposed changes to Medicaid coverage under Kentucky HEALTH. Three changes – copays, loss of dental and vision coverage, and ending non-emergency medical transportation – were reversed by the state after Boasberg’s decision. The remaining changes mostly revolve around work requirements, including reporting time worked or hours volunteered, and restricting who is allowed to apply for the medically frail designation.
Advocates say the changes will create an undue burden for many current recipients of Medicaid, especially those living in rural areas, where access to reliable transportation and internet will hinder their ability to meet and report work and volunteer requirements.
“There’s a very serious disconnect between what the state has laid out, and what the reality is for the people of Kentucky,” Koch said. “It will be almost impossible [to meet the new requirements], and it’s the poorest in the state that are going to hurt the most from it.”
Dr. Bill Collins is a general practice dentist working in Eastern Kentucky. He works three days a week at the nonprofit Red Bird Clinic in Beverly, where almost 80 percent of his patients are Medicaid recipients. Beverly is very rural, and most of the residents do not have internet access, and would have to drive 45 minutes one way to get to a public library where they would have access.
“You are talking about the working poor and the poor,” Collins said. “They can’t afford to be hooked up to scarcely provided cable service for expensive Internet.”
It’s clear to Collins that the Bevin administration did not consider these geographic and technological barriers when they designed their Medicaid waiver. Another issue raised by critics is that many Medicaid recipients are already working part-time jobs – as waitstaff at restaurants or at places like Walmart. Having seasonal or hourly jobs could mean they lose coverage under the proposed requirements depending on how many hours they are allowed to work.
“How does a person that makes $2.20 an hour plus tips and has two kids and is also helping their mom afford a $15 a month premium plus co-pays?” Collins said. “[The state is] denying access to care, plain and simple.”
If Medicaid recipients are unable to report changes in income or report their work requirements within 30 days, they will be locked out of coverage for six months.
“A sixth-month blackout is devastating for someone who needs any kind of regular medication,” said Koch.
Devon McCormick is a 35-year-old preschool and kindergarten teacher in Monroe County, Kentucky. After becoming sick with three chronic health conditions, she was forced to stop teaching and is now on medical disability. Medicaid allows her to make necessary appointments with her primary care provider and specialists to manage her health conditions.
“Without Medicaid or insurance, I would not be able to go [to the doctor],” McCormick says. “I hope to return to teaching one day. If I do not have insurance, I will not be well enough to return.”
McCormick has received notification under the proposed Medicaid waiver saying she will need to meet work requirements to maintain coverage. Her chronic health issues will prevent her from doing so. She’s a former teacher, and is classified as disabled under the teachers’ pension, which is separate from other forms of state benefits. Because of different requirements in the systems, the Medicaid system does not recognize her as disabled.
“I get very nervous and anxious when changes are made,” McCormick says. “I have very little control over what is happening, but the changes affect me greatly. I need this insurance.”
Misty Skaggs is a writer in Elliot County, Kentucky, and says she and a lot of her family and friends depend on Medicaid for basic medical care. She says she’s worried constantly about her mother who needs knee surgery she can’t afford, and that her friend won’t be able to afford the insulin she needs from month to month. She’s currently organizing a benefit concert to raise money to help build a wheelchair ramp for her cousin’s wife – a ramp she could not afford otherwise.
“If we don’t support each other in Appalachia, we could literally die,” Skaggs says. “I’m just doing my damndest to take care of me and mine, and to help people where I can, however I can.”
She hasn’t received any notification yet that she’ll need to meet work requirements to maintain coverage, but says she expects to see a letter any day now.
Many advocates and providers, including Collins, agree that if the concern is making sure Medicaid recipients are working, there are other ways to do that than threatening to take away their access to healthcare. Dustin Pugel, policy analyst at the Kentucky Center for Economic Policy, says the Paths to Promise pilot program in Eastern Kentucky’s Promise Zone counties is a good example of what’s possible. It’s funded through the USDA and SNAP program, and provides employment supports to low-income people who otherwise wouldn’t have access to transportation, career counseling, childcare, or other necessary tools to advancing job prospects.
“It’s definitely true that just requiring people to do these jobs [through work requirements] is also not going to create great paying jobs,” Pugel said. “There are other ways to increase economic development and create jobs and to do workforce development than attaching those things to healthcare.”
Pugel says the state is very confident they will be allowed to implement Kentucky HEALTH as soon as October 1. This could mean a lot of trouble for providers. Collins says if the waiver goes through, he will have no choice but to stop accepting Medicaid patients at his private practice in Pikeville. The administrative costs will be too high. The fate of Red Bird Clinic is more uncertain.
“We will work there as long as the money holds out,” Collins said. “We still have bills to pay, lab expenses, supplies, payroll and all the normal cost of business. It will really complicate things.”
During the brief time period when dental and vision coverage was suspended under Medicaid, Collins did not take any new patients at Red Bird Clinic, and limited treatment of Medicaid patients at his private practice to those who were in pain, eating the cost that patients couldn’t afford to pay.
“Medicaid is not and should not be a way of life, but it is a way out of poverty,” Collins said. “I totally agree with work ethics, but I also know you have to crawl before you walk and walk before you run. I was not an Obama supporter; I am a mountain supporter. I am whatever takes care of my people.”
Tara Boling is the Director of Medical Case Management at Mathew 25 AIDS Services in Western Kentucky. The nonprofit covers 25 counties in Kentucky, and seeks to support, educate and treat those infected with and affected by HIV/AIDS.
“We don’t have the funds to provide free medical care, prescription drugs and taxi services to all. We need help,” Boling said.
Boling said that billing Medicaid for medical, dental and vision care, as well as transportation costs, allows Mathew 25 to spend their limited resources on other necessary services to help support their patients, like housing assistance, substance abuse, and mental health counseling, groceries, and child care.
Boling says the rapid changes being made are causing confusion and anxiety among her patients, many of whom use Medicaid to access life-saving medication. Though many of her patients have been designated as medically frail by the state, she says it’s not entirely clear whether or not they will still need to meet certain requirements to maintain coverage. Without taking their medications, she says they could become seriously ill and be at greater risk of transmitting HIV/AIDS to others. In both scenarios, she says the burden will eventually fall on taxpayers.
“One way or another this falls on taxpayers, so we might as well pay up front to protect lives,” Boling says.
If the waiver is approved, Pugel is “certain that it will be relitigated in some way.” He says it will either be sent up to the Supreme Court, or it will be rolled back by a new administration if a new governor is elected in 2019. The Kentucky Equal Justice Center, Southern Poverty Law Center and the National Health Law Project are representing 15 Kentucky plaintiffs, and have all said they are prepared to relitigate after October 1.
For now, Kentucky has the same kind of Medicaid expansion under Bevin that it had under the previous administration, with the same requirements, same benefits, and being reimbursed the same way.
“The law has protected Medicaid. These changes are illegal. These changes do not support the purposes of Medicaid as written in the Social Security Act, and so, when the Trump and Bevin administrations tried to bend or break that law, the court stepped in and said, ‘No, you can’t do that,’” Pugel said.
Koch says that whatever happens with the waiver, KVH will continue doing all that it can to provide Kentuckians with the most up-to-date information they have in order to keep people informed of their coverage options and their rights to healthcare access.
“It’s going to be a battle to try and help folks navigate this incredibly complex system,” Koch said. “But we’re ready to fight that fight.”
Ivy Brashear is the Appalachian Transition Coordinator at the Mountain Association for Community Economic Development in Berea, Ky.