One can say this about the hoops Kentucky will require low-income residents to jump through to become eligible for Medicaid: If you were deliberately trying to come up with ways to throw people off the program, you couldn't do better.
It's been widely reported that the "waiver" of Medicaid rules approved for the state by federal officials last week includes a first-in-the-nation work requirement. (Our initial take on the waiver can be found here.) But there's much more to it, none of it good if you are a Medicaid enrollee or someone who believes that the purpose of government healthcare programs is to provide people with healthcare.
"Coverage is at risk for large numbers of low-income adults and families," says Judith Solomon, a health policy expert at the Center on Budget and Policy Priorities. Kentucky's own figures show that as many as 100,000 people could lose their coverage within five years — that's about 15% of the state's Medicaid population. "Many of those affected are likely to be older, and many will be people who suffer from mental illness, substance use disorders, and chronic health problems," Solomon says.
What's more disturbing is that Kentucky's changes, if they can pass legal muster, could be the precursor of similar approaches in states such as Arizona, Arkansas, Indiana, Kansas, Maine, Wisconsin and Utah, where Republican leaders have filed applications resembling Kentucky's.
Kentucky's program bristles with paperwork requirements and Catch-22s that could easily lead even those who meet the work requirements to "trip up and become uncovered," Solomon says. That's because the program includes a "lockout" if enrollees fail to revalidate their eligibility every year or miss one or another deadline for paperwork: In those cases, they could be denied benefits for as long as six months.
As we reported earlier, Kentucky's tea-party Gov. Matt Bevin, who took over from Democrat Steve Beshear in 2015, is inordinately proud of this outcome. He calls the changes "transformational."
Another person who should be ashamed, not proud, of the program is Seema Verma, who oversees Medicaid as administrator of the Centers for Medicare and Medicaid Services. Verma's department issued the guidelines last week under which Kentucky's work and other requirements were approved the very next day. More to the point, as a private consultant prior to becoming head of the centers, she helped Kentucky draft the waiver application that her underlings approved. (Verma said she recused herself from ruling on the Kentucky application, which deserves a response of: Pu-leeze.)
Before we list the exceptionally punitive aspects of the Kentucky plan, it's proper to note that this is a radical change of direction for the state. Until Bevin's election, the state was one of the distinct success stories of the Affordable Care Act. Under Beshear, Kentucky set up its own ACA exchange, the widely popular Kynect, and expanded Medicaid. As a consequence, it registered the largest reduction in the uninsured rate of any state in the nation — 12.6 percentage points, bringing its uninsured rate to 7.8% in 2016 — better even than California, which similarly went all-in on Obamacare.
Bevin campaigned on a platform of undoing all this, and won in an election with a civically atrocious low turnout. He hasn't been able to do all the damage he promised, but the waiver approved last Friday is a big step in that direction.
Under Kentucky's program, Medicaid enrollees will have to work or perform job-related activities — job hunting, training, volunteering, GED or community college class time — of at least 80 hours a month. The mandate is aimed at adults receiving Medicaid expansion coverage. The main exemptions are for children, pregnant women and the "medically frail" (a term the state has not defined). Enrollees will have to recertify their eligibility every year.
The punitive lockout — another provision Medicaid approved for the first time, has family healthcare advocates aghast. "All parents are subject to the lockout," says Joan Alker, executive director of Georgetown University's Center for Children and Families. That jeopardizes their children's health, she says, since healthy parents are more likely to make sure their children are medically cared for. Moreover, "an uninsured parent threatens the financial security of the entire family."
Kentucky is imposing obstacles to enrollment and renewal. They include premiums initially ranging from $1 to $15 a month. The state can raise those premiums to as much as 4 percent of household income without seeking federal permission. For an individual at the poverty line of $12,060 this year, or about $1,000 a month, that would come to $40 a month.
That could be a significant obstacle for a family living on the economic edge and facing an unexpected expense. Anyone above the poverty line who falls 60 days behind on premiums will lose coverage for six months. (They can re-enroll if they pay their past-due premiums and take a financial or health literacy course, the Center on Budget and Policy Priorities observes.) People below the poverty line who fail to pay will lose coverage for up to 60 days.
All this runs directly counter to the principles that have governed Medicaid since its inception in 1965. "The lessons of history are clear," says Alker. "When the renewal process becomes more difficult and other bureaucratic obstacles to enrolling in coverage are raised, people will lose coverage. This is often the explicit intent of these policies. Conversely, simplifying enrollment and renewal policies has been an important contributor to the nation's historic success in reducing the rate of uninsured children.
What's bizarre to the point of insanity about these changes in Kentucky's healthcare policies is that few states need the government's help in making its residents healthier than this one. According to the state's own figures — mustered, oddly, to justify cutting back on Medicaid — it's one of the unhealthiest states in the union. It ranks worst in the nation in cancer death rates, has the second-highest smoking rate and seventh highest obesity rate. Eight of the 13 counties in the U.S. with the largest declines in life expectancy are in Kentucky.
In the face of this grim profile, Gov. Matt Bevin thinks too many Kentuckians get too much healthcare. We'd ask what he's thinking, but plainly he isn't thinking at all.